Aims. The escalating demand for medical resources to address spinal diseases as society ages is an issue that requires careful evaluation. However, few studies have examined trends in spinal surgery, especially unscheduled hospitalizations or surgeries performed after hours, through large databases. Our study aimed to determine national trends in the number of spine surgeries in Japan. We also aimed to identify trends in after-hours surgeries and unscheduled hospitalizations and their impact on complications and costs. Methods. We retrospectively investigated data extracted from the Diagnosis Procedure Combination database, a representative inpatient database in Japan. The data from April 2010 to March 2020 were used for this study. We included all patients who had undergone any combination of laminectomy, laminoplasty, discectomy, and/or spinal arthrodesis. Results. This investigation included 739,474 spinal surgeries and 739,215 hospitalizations in Japan. There was an average annual increase of 4.6% in the number of spinal surgeries. Scheduled hospitalizations increased by 3.7% per year while unscheduled hospitalizations increased by 11.8% per year. In-hours surgeries increased by 4.5% per year while after-hours surgeries increased by 9.9% per year. Complication rates and costs increased for both after-hours surgery and unscheduled hospitalizations, in comparison to their respective counterparts of in-hours surgery and scheduled hospitalizations. Conclusion. This study provides important insights for those interested in improving spine care in an ageing society. The swift surge in after-hours spinal surgeries and unscheduled hospitalizations highlights that the medical needs of an increasing number of patients due to an ageing society are outpacing the capacity of existing medical resources. Cite this article: Bone Jt Open 2024;5(8):662–670

We reviewed 212 consecutive patients with adolescent idiopathic scoliosis who underwent posterior spinal arthrodesis using all pedicle screw instrumentation in terms of clinical, radiological and Scoliosis Research Society (SRS)-22 outcomes. In Group 1 (51 patients), the correction was performed over two rods using bilateral segmental pedicle screws. In Group 2 (161 patients), the correction was performed over one rod using unilateral segmental pedicle screws with the second ^{rod providing stability of the construct through two-level screw fixation at proximal and distal ends. The mean age at surgery was 14.8 years in both groups. Comparison between groups showed no significant differences with regard to age and Risser grade at surgery, pre- and post-operative scoliosis angle, coronal Cobb correction, length of hospital stay and SRS scores. Correction of upper thoracic curves was significantly better in Group 1 (p = 0.02). Increased surgical time and intra-operative blood loss was recorded in Group 1 (p < 0.001 and p = 0.04, respectively). The implant cost was reduced by mean 35% in Group 2 due to the lesser number of pedicle screws.}

Unilateral and bilateral pedicle screw techniques have both achieved excellent deformity correction in adolescent patients with idiopathic scoliosis, which was maintained at two-year follow-up. This has been associated with high patient satisfaction and low complication rates.

Cervical spinal arthrodesis is the standard of care for the treatment of spinal diseases induced neck pain. However, adjacent segment disease (ASD) is the primary postoperative complication, which draws great concerns. At present, controversy still exists for the etiology of ASD. Knowledge of cervical spinal loading pattern after cervical spinal arthrodesis is proposed to be the key to answer these questions. Musculoskeletal (MSK) multi-body dynamics (MBD) models have an opportunity to obtain spinal loading that is very difficult to directly measure in vivo. In present study, a previously validated cervical spine MSK MBD model was developed for simulating cervical spine after single-level anterior arthrodesis at C5-C6 disc level. In this cervical spine model, postoperative sagittal alignment and spine rhythms of each disc level, different from normal healthy subject, were both taken into account. Moreover, the biomechanical properties of facet joints of adjacent levels after anterior arthrodesis were modified according to the experimental results. Dynamic full range of motion (ROM) flexion/extension simulation was performed, where the motion data after arthrodesis was derived from published in-vivo kinematic observations. Meanwhile, the full ROM flexion/extension of normal subject was also simulated by the generic cervical spine model for comparative purpose. The intervertebral compressive and shear forces and loading-sharing distribution (the proportions of intervertebral compressive and shear force and facet joint force) at adjacent levels (C3-C4, C4-C5 and C6-C7 disc levels) were then predicted. By comparison, arthrodesis led to a significant increase of adjacent intervertebral compressive force during the head extension movement. Postoperative intervertebral compressive forces at adjacent levels increased by approximate 20% at the later stage of the head extension movement. However, there was no obvious alteration in adjacent intervertebral compressive force, during the head flexion movement. For the intervertebral shear forces in the anterior-posterior direction, no significant differences were found between the arthrodesis subject and normal subject, during the head flexion/extension movement. Meanwhile, cervical spinal loading-sharing distribution after anterior arthrodesis was altered compared with the normal subject's distribution, during the head extension movement. In the postoperative loading-sharing distribution, the percentage of intervertebral disc forces was further increased as the motion angle increased, compared with normal subject. In conclusion, cervical spinal loading after anterior arthrodesis was significantly increased at adjacent levels, during the head extension movement. Cervical spine musculoskeletal MBD model provides an attempt to comprehend postoperative ASD after anterior arthrodesis from a biomechanical perspective

Instrumented spinal arthrodesis is a common procedure to correct scoliosis. The long-term consequences of these retained implants is unclear. Concern of possible toxic effects of raised metal ion levels have been reported in arthroplasty literature. We investigated serum metal ion levels in patients having instrumented spinal arthrodesis for scoliosis correction. The study included patients who underwent posterior spinal arthrodesis using Isola stainless steel instrumentation for scoliosis between 1998 and 2002. Patients having post-operative complications, instrumentation removed, revision surgery or additional in situ metal implants were excluded. Participants completed a questionnaire to evaluate exogenous chromium exposure. Serum levels of chromium, molybdenum, iron and ferritin were measured in venous blood samples. Participants with elevated serum chromium levels underwent further erythrocyte chromium analysis. Comparisons were made with two control groups;. “non-instrumented” individuals with scoliosis and. “normal” unaffected volunteers. All control group participants underwent serum and erythrocyte analysis (as above). Thirty “instrumented” patients (Group 1, 26 females and 4 males), 10 “non instrumented” patients with scoliosis (Group 2) and 10 unaffected volunteers (Group 3) were included in the study. Mean age at surgery was 13.8 years (range 6.6 to 13.2), mean time from surgery 5.7 years (range 3.4 to 8.1). Elevated serum chromium levels were demonstrated in 11/30 (37%) Group 1 participants. In the control groups, elevated serum chromium levels were demonstrated in 0/10 (0%) in Group 2 and 2/10 (20 %) in Group 3. There was a statistically significant (p=0.001) elevation in serum chromium levels between scoliosis participants with retained spinal implants, and those without. There was no significant correlation found between Groups 1, 2 and 3 for serum molybdenum, iron and ferritin levels. Erythrocyte chromium measurements from all participants (n=31, 100%) were considered within the normal range. At a multivariant level, the results of a stepwise censored regression (n=50) indicated the significant predictors of serum chromium to be spinal implants (p=0.001), gender (male versus female, p=0.04) and iron grading (low, normal or high, p=0.05). Time since surgery was found not to have a significant correlation with chromium levels (p=0.147). Raised serum chromium levels were detected in 37% of patients after instrumented spinal arthrodesis for scoliosis correction. This new finding has relatively unknown health implications but potential genotoxic, dysmorphic and carcinogenic sequelae; this is especially concerning with most scoliosis patients being adolescent females with their reproductive years ahead

Summary of background data. The development of a spinal deformity, usually affecting the coronal and occasionally the sagittal balance of the spine is a recognised complication of paralysis following a spinal cord injury (SCI) occurring in childhood. Purpose of the study. The aim of the present study was to report our experience on the surgical treatment of patients who developed a paralytic spinal deformity secondary to SCIs occurring in childhood. Material-Methods. Our study cohort comprised 18 consecutive patients with a paralytic spinal deformity as a consequence of a SCI. The cause of paralysis in this group of patients included a traumatic incident in 10 patients, spinal cord tumour in 6 patients, vascular injury to the neural cord during cardiac surgery in one patient, and meningitis in one patient. Twelve patients presented with high- or mid-thoracic paraparesis, which was complete in all but two patients. Six patients developed tetraparesis, which was incomplete in 3 of these patients. Results. Fourteen patients underwent surgical correction of their spinal deformities; 11 patients had a scoliosis, 2 had a lordoscoliosis, and one had a kyphosis. The mean age at spinal arthrodesis was 13.4 years. Eleven patients underwent a posterior spinal fusion alone and 3 patients underwent a combined anterior and posterior spinal arthrodesis. Posterior spinal instrumentation with bilateral Luque rods and segmental fixation with sublaminar wires was used in all but one patient who was stabilised with the use of third generation spinal instrumentation. The spinal fusion extended to the sacrum in 10 of the 14 patients (71.4%) using the Galveston technique of intra-iliac pelvic fixation. None of the patients developed postoperative wound infections, either early or late. There were no major medical complications following surgery in this group of patients that would result in prolonged intensive care unit or hospital stay. Four of the 14 patients (28.6%) who had initially undergone a posterior spinal arthrodesis alone developed an asymptomatic pseudarthrosis with failure of the instrumentation. The non-union was treated successfully in 2 of these 4 patients with a combined anterior and posterior spinal fusion. The repair of the pseudarthrosis was performed through a repeat posterior spinal fusion in the remaining 2 patients and one of these patients necessitated a second revision procedure to address recurrence of the non-union. Conclusions. The high rate of pseudarthrosis (28.6%) recorded in the present series suggests that a combined anterior and posterior spinal arthrodesis could be considered as the initial treatment of choice for patients who are at a good general medical condition to tolerate anterior surgery and who have severe deformities. If pseudarthrosis develops following an isolated posterior spinal fusion, this can be treated more effectively by a combined anterior and posterior revision procedure with the use of instrumentation, which can increase the chances for a successful outcome

Introduction: Spinal arthrodesis with stainless steel implants is a common procedure to correct scoliosis however, the long-term consequences of retained implants is unclear. Raised serum metal ion levels have been widely published in arthroplasty literature with concern over possible toxic adverse effects associated with chronic exposure. We investigated serum metal ion levels in patients who had undergone instrumented spinal arthrodesis for scoliosis correction. Methods: The study included patients who underwent posterior spinal arthrodesis using ISOLA instrumentation for scoliosis between 1998 and 2002. The minimal period of follow up was 3 years. Clinical information was available from a comprehensive Scoliosis Database, Department of Orthopaedic Surgery, Women’s and Children’ Hospital, Adelaide (WCH). Patients having post-operative complications, spinal instrumentation removed, revision surgery or additional in situ metal implants were excluded. Participants completed a questionnaire to evaluate exogenous chromium exposure. Blood samples were collected and processed by the WCH Core Laboratory. Serum levels of chromium, molybdenum, iron and ferritin were measured by Sydney South West Pathology Service. Participants with serum chromium levels outside the normal reference range underwent further analysis to evaluate chromium levels in erythrocyte haemolysate preparations (to assess the valency of abnormal chromium levels detected). Comparisons were made with two control groups; the first being individuals with scoliosis who had not undergone operative intervention and the other, “normal” unaffected volunteers. All control group participants underwent serum and erythrocyte analysis (as above). Ethics approval was obtained from the WCH Research Ethics Committee. Results: Thirty patients (26 females and 4 males) who underwent instrumented scoliosis surgery, 10 non instrumented scoliosis patients and 10 unaffected volunteers were included in the study. Mean age of the operative group at surgery was 13.8 years (11.1–16.9) with a mean length of time from surgery of 5.8 years (3.5–8.2). In the study group, raised serum chromium levels were demonstrated in 11/30 (36.6%) of patients. Five of the 11 patients with raised chromium levels also had low levels of serum iron and/or ferritin. Erythrocyte levels of chromium were undetectable in all of the 11 (100%) patients. There did not appear to be an exogenous source of chromium exposure in any of these patients. In the non-operative control group with scoliosis, none had elevated serum chromium, iron or ferritin levels. 2/10 (20%) had high molybdenum levels. In the unaffected control group, 1/10 (10%) had raised serum chromium and molybdenum levels. Three control patients had low levels of serum iron and/or ferritin. All control participants, but one, had undetectable erythrocyte chromium levels. There was a significant difference in serum chromium levels between the study and control groups (p=0.01) with the group of patients who underwent instrumented scoliosis surgery having a greater proportion with high chromium and lower proportion with normal chromium. Discussion: Raised serum chromium levels were detected in patients after instrumented spinal arthrodesis for scoliosis correction. This new finding in young patients has relatively unknown health implications but potential genotoxic and carcinogenic sequelae; this is especially concerning with most scoliosis patients being female and with their reproductive years ahead. These findings should prompt further research in this area, particularly to similarly investigate other spinal implant systems and assess the long term implications of raised chromium levels

Scheuermann's kyphosis is a structural deformity of the thoracic or thoracolumbar spine, which can result in severe pain, neurological compromise and cosmetic dissatisfaction. Modern surgical techniques have improved correction through a posterior-only or antero-posterior approach but can result in significant morbidity. We present our results of the surgical management of severe Scheuermann's kyphosis by a single surgeon with respect to deformity correction, global balance parameters, functional outcomes and complications at latest follow-up. We included 49 patients, of which 46 had thoracic and 3 had thoracolumbar kyphosis. Surgical indications included persistent back pain, progressive deformity, neurological compromise and poor self-image. Fourty-seven patients underwent posterior-only and 2 antero-posterior spinal arthrodesis utilising Chevron-type osteotomies and hybrid instrumentation. Mean age at surgery was 16.0 years with mean postoperative follow-up of 4.5 years. Mean kyphosis corrected from 92.1o to 46.9o (p<0.001). Concomitant scoliosis was eliminated in all of the 28 affected patients. Coronal and sagittal balance was corrected in all patients. Mean blood loss was 24% total blood volume. Mean operation time was 4.3 hours with mean inpatient stay of 9 days. SRS-22 questionnaire improved from a mean preoperative score of 3.4 to 4.6 at 2 years, with high treatment satisfaction rates. Complications included one toxic septicaemia episode but otherwise no wound infections, no junctional deformity, no loss of correction and no requirement for re-operation. Posterior spinal arthrodesis with the use of hybrid instrumentation can safely achieve excellent correction of severe Scheuermann's kyphosis helping to relieve back pain, improve functional outcomes and enhance self-image

Aim:. To determine radiographic variables that predict the need for distal extension of the fusion beyond Cobb-to-Cobb levels in treating thoracolumbar/lumbar (TL/L) scoliosis (Lenke 5) in adolescent patients. Method:. We reviewed the medical notes and radiographs of the senior author's consecutive series of 53 adolescent patients with TL/L scoliosis treated by posterior instrumented spinal arthrodesis using an all-pedicle screw construct. Our patients were categorised into 2 groups: patients with instrumented fusion between Cobb-to-Cobb levels of the TL/L curve (Group 1), and patients that required distal extension beyond the caudal Cobb level (Group 2). Pearson correlation and binary logistic regression analyses (significance p<0.05) were performed to identify variables that predict the need for distal extension. Results:. Groups 1 and 2 comprised 36 and 17 patients, respectively. The following preoperative parameters significantly correlated with distal extension of the fusion: TL/L scoliosis angle (TL/L), TL/L supine maximum lateral bending angle, TL/L apical vertebral translation (AVT), TL/L flexibility index (FI), lowest instrumented vertebra angle (LIVA), and compensatory thoracic scoliosis angle (TH). Binary logistic regression analysis optimised a predictive equation incorporating TL/L, AVT, FI, LIVA, and TH parameters that provides an 81% accuracy in predicting the need for Cobb-to-Cobb fusion or distal extension. There was no difference in demographic data or SRS-22 scores between the 2 groups. Discussion:. Regression analysis of preoperative radiographic variables can accurately predict the need for distal extension of the fusion beyond the preoperative Cobb-to-Cobb levels during posterior spinal arthrodesis in patients with adolescent idiopathic thoracolumbar/lumbar scoliosis. Conflict Of Interest Statement: No conflict of interest

Introduction. This research determines the feasibility of radiostereometric analysis (RSA) as a diagnostic tool for assessing fusion following spinal arthrodesis. Further, to estimate clinical thresholds for precision and accuracy of the proposed method in the cervical and lumbar spine. Methods. Two-level lumbo-sacral and three-level cervical posterior arthrodesis procedures were performed on an artificial spine model and a cadaveric spine (Figure 1). Using a spring-loaded inserter, RSA marker beads were placed within each of the L4-S1 and C3-C6 vertebrae, then analyzed for optimal bead distribution and detection. RSA imaging consisted of 12 double exams (24 exams) of the cervical and lumbar regions for both the Sawbones and cadaveric spine to assess precision of measurement under zero-displacement conditions, defined as the 95% confidence interval of error. Accuracy assessment was performed on the Sawbones model in which the middle vertebrae (L5 and C4-C5) were moved relative to the superior (L4 and C3) and inferior (S1 and C6) vertebrae by known, incremental displacements (Figure 2). RSA images were obtained at each displacement (Figure 3). Accuracy was defined as the mean difference between known and measured displacements. Results. Median RSA bead detection was 100% in cervical vertebrae and >75% in lumbar vertebrae in the artificial and cadaveric models. Translational RSA precision for both spine models was better than 0.25mm and 0.82mm for the lumbar and cervical regions, respectively. Rotational precision was better than 0.4° and 1.9° for the lumbar and cervical regions, respectively. RSA accuracy for the artificial spine overall demonstrated less than 0.11 mm translational bias (margin < ±0.02 mm) and less than 0.22° rotational bias (margin < ±0.15°). Discussion and Conclusion. This study demonstrates that RSA achieves sufficient precision and accuracy to detect intervertebral micromotion for the purpose of assessing arthrodesis. Well dispersed bead placement is critical to achieving sufficient accuracy and avoiding occlusion by metal hardware. The results of this work will aid in the development of a clinical study to assess arthrodesis in patients. For any figures or tables, please contact the authors directly

The purpose of this research was to determine the feasibility of radiostereometric analysis (RSA) as a diagnostic tool for assessing non-union following spinal arthrodesis procedures. Further, to estimate clinical thresholds for precision and accuracy of the proposed method in the cervical and lumbar spine. A three-level lumbo-sacral and a four-level cervical posterior arthrodesis procedures were performed on an artificial spine model (Sawbones, WA). Using a spring loaded inserter (RSA Biomedical, Sweden), eight to ten RSA markers were placed within each of the L4 and L5 segments in the spinous process (L4 only), lamina, transverse processes, posterior and anterior (down the pedicle) wall of the vertebral body. Eight to ten markers were placed within the proximal sacrum (S1) at the medial and lateral crests, tuberosity, and within the sacral canal wall. Four to eight RSA markers were placed into the C3-C6 lateral masses. Titanium screws and rods were applied to the spinal segments. Identical procedures were then performed on a cadaveric spine using similar bead placement and hardware. RSA imaging consisted of 12 double exams (24 exams) of the cervical and lumbar regions for both the Sawbones and cadaveric spine to assess precision of measurement under zero-displacement conditions. The most distal vertebrae were considered the datum against which the movement of all other vertebrae was compared. The artificial spine was then dismantled for accuracy assessment in which the middle vertebrae (L5 and C4-C5) were moved relative to the superior (L4 and C3) and inferior (S1 and C6) vertebrae by known, incremental displacements on an imaging phantom device. Displacements occurred along the superior-inferior, anterior-posterior, and flexion-extension (rotational) axes of motion. RSA images were obtained at each displacement. Image analysis was performed using model-based software (RSACore v3.41, Leiden, Netherlands) to visualize implanted RSA beads in 3-D space. Precision was defined as the 95% confidence interval of error in measuring zero-displacement. Accuracy was defined as the mean difference (with 95% confidence interval) between the known and measured displacement. The rate of RSA bead detection was high with 5–8 implanted beads being visible in both the lumbar and cervical regions of the artificial and cadaveric spines. Translational RSA precision for both spines was better than 0.25 mm and 0.82 mm for the lumbar and cervical regions, respectively. Rotational precision was better than 0.40° and 1.9° for the lumbar and cervical regions, respectively. RSA accuracy for the artificial spine overall demonstrated less than 0.11 mm translational bias (margin < ±0.02 mm) and less than 0.22° rotational bias (margin < ±0.15°). This study demonstrates that RSA achieves sufficient precision and accuracy to detect intervertebral micromotion for the purpose of assessing arthrodesis. Well dispersed RSA bead placement is critical to achieving sufficient accuracy as well as avoiding occlusion by metal hardware. Cervical bead implantation is particularly sensitive to bead clustering due to small vertebrae size and proximity to critical structures. The results of this work will aid in the development of a clinical study to assess arthrodesis in patients

Aim:. To present 11 patients with quadriplegia who developed severe lordoscoliosis or hyperlordosis. This is a rare deformity in children with CP, treatment is challenging and there are less than 20 patients ever reported. Method:. All patients underwent posterior spinal arthrodesis at mean age 14.6 years with mean follow-up 3.5 years. We measured all radiographic parameters including coronal and sagittal balance and sacral slope before and after surgery. Results:. Mean preoperative lumbar lordosis was 107°. This corrected to mean 63° at follow-up. Mean preoperative thoracic kyphosis was 13°. This improved to mean 47° at follow-up. Mean preoperative scoliosis was 80°. This corrected to mean 22o at follow up. Mean preoperative pelvic obliquity was 22°. This corrected to mean 4° at follow-up. Mean preoperative sacral slope was 80o. This corrected to mean 51o at follow-up. Mean preoperative coronal imbalance was 5.2 cm. This corrected to mean 0.6 cm at follow-up. Mean preoperative sagittal imbalance was 8 cm. This corrected to mean 1.6 cm at follow-up. Mean surgical time was 260 minutes. Mean intra-operative blood loss was 0.82 EBV. Mean stay in ICU was 3.6 and in hospital 15.2 days. Complications included 3 patients with severe blood loss (1.3–2 EBV), one patient with chest and one chest and urinary infection, and a patient with superior mesenteric artery syndrome. Increased preoperative lumbar lordosis and sacral slope correlated with surgical and postoperative morbidity. In contrast, there was no correlation between preoperative scoliosis or pelvic obliquity and surgical morbidity. Reduced lumbar lordosis and increased thoracic kyphosis correlated with better global sagittal balance at follow-up. Greater surgical time and blood loss correlated with increased postoperative morbidity. All 11 patients and their parents reported excellent feedback on the outcome of surgery with major improvement in physical appearance, sitting balance and relief of severe preoperative back pain. Discussion:. Lordoscoliosis and hyperlordosis are associated with significant morbidity in patients with quadriplegia. The sagittal imbalance is the major component of the deformity and this can be corrected satisfactorily through a posterior spinal arthrodesis which produced excellent functional results and increased patients'/caretakers' satisfaction. Conflict Of Interest Statement: No conflict of interest

OP-1 is a bone morphogenetic protein which induces bone formation. For this reason, this protein is used to treat congenital pseudoarthrosis and post-traumatic non-union as well as to improve healing of bone grafting in orthopaedic surgery. In the present study we report the results of treatment in 10 patients in whom OP-1 was used to improve bone healing. Four patients were operated because of post-traumatic non-union, one because of congenital pseudo-arthrosis and four because of spinal arthrodesis, whereas one had a tibial lenghthening with poor bone formation. At follow-up, ranging from 6 to 16 months after the operation, we observed satisfactory bone formation in all cases. Although the number of our cases is limited, our results confirm the effectiveness of OP-1 in the treatment of post-traumatic non-union and spinal arthrodesis

Purpose. Bone morphogenic protein (BMP-2) is used in spinal arthrodesis to induce bone growth. Studies have demonstrated that it achieves similar fusion rates compared to iliac crest bone graft when used in instrumented fusions. Our study aims at evaluating the requirement for instrumentation in one and two-level spinal arthrodeses when BMP-2 is used in conjunction with local bone to achieve fusion. Method. 50 patients were recruited and randomized to instrumented versus non-instrumented spinal arthrodesis. BMP-2 with local autologous bone was used in all patients. Patients are evaluated at 3-months, 6-months, 12-months, and 24-months postoperatively with questionnaires to assess clinical outcome (ODI, VAS and SF-36), and PA and lateral x-rays of the spine to assess radiographic fusion (Lenke score). At 24 months, a thin-cut (1mm) CT scan was performed. Results. Two-year data is available on 40 patients. There were no statistically significant differences between the two groups based on the clinical outcomes measured. The ODI 22.55.1 for the instrumented group vs. 13.733.57 for the non-instrumented group (p=0.2)). The VAS for the instrumented group was 2.110.61 vs. 1.530.61 for the non-instrumented group (p=0.49). The SF-36 (physical) was 62.316.71 for the instrumented group vs 54.665.43 for the study group (p=0.8). The operating time was 105.85.91 minutes for the instrumented group versus 88.63.61 minutes for the non-instrumented group (p=0.01). Blood loss was 339.139.38 cc for the instrumented group vs 273.133.8 cc for the non-instrumented group (p=0.1). Preliminary radiographic analysis showed similar fusion rates for the two groups. Two-year follow-up on all patients will be completed by February 2010. Final clinical and radiographic data analysis will be presented at the meeting. Conclusion. BMP-2 and local bone graft demonstrated functionally equivalent clinical outcomes when used with or without instrumentation in lumbar spinal fusions while offering potential reduction in operative time and blood loss

Introduction: Spinal deformities (scoliosis, kyphosis or kyphoscoliosis) in children under 10 years of age result from congenital, neuromuscular and idiopathic etiologies. The progression of the deformity is affected by its nature, location and age of onset. Spinal arthrodesis is the procedure of choice in patients with progressive deformities. The use of instrumentation facilitates curve correction and arthrodesis rates. Pediatric spinal surgery is technically demanding, and is still considered controversial. The advent of reduced size spinal instrumentation allowed surgeons to expand their use to pediatric patients. The use of spinal instrumentation in children with various spinal deformities has not been well documented. Objective: To assess the safety and efficacy of spinal arthrodesis in young patients with progressive spinal deformities. Patients and Methods: We retrospectively reviewed the medical charts and radiographs of 25 patients younger than 10 years of age who underwent corrective surgery for various spinal deformities. Radiographic outcome, fusion rates and complication were compared between instrumented and non instrumented patients. Results: At two years of follow up instrumented corrective procedures resulted in superior correction compared to non-instrumented patients and in solid arthrodesis in all. Complications were infrequent. Conclusions: The use of reduced size spinal instrumentation in young patients with progressive spinal deformities is safe and effective. Curve correction, length of bracing and fusion rates are all in favour of instrumentation, wile complication rates are acceptable. The use of spinal instrumentation in young patients requires expertise and patience

Introduction and Aims: Elevated chromium ion levels can be detected in serum following spinal arthrodesis with stainless steel. Comparing characteristics of spinal implants with chromium levels has not been done extensively before. The aim of our study was to compare an extensive range of implant characteristics with chromium levels. Methods: Cross-sectional study of 30 patients (26 females and 4 males) who underwent posterior instrumented spinal arthrodesis using Isola implants including cables for adolescent scoliosis between 1998 and 2002. Patients who had postoperative complications and implants removed were excluded. Serum levels of chromium were analysed between October 2006 and June 2007. Post-operative radiography was used to measure rod length and count hooks, screws, cross-connectors and cables. Surface areas of each component of the implant was estimated and totalled. Metal-on-metal interfaces were calculated. Ethics approval was obtained from the WCH Research Ethics Committee. Results: Both total surface area and total rod length were correlated with serum chromium levels (p = 0.04 and 0.05 respectively). This is the first study to identify a characteristic of spinal implants, other than the late signs of corrosion identified by radiographs, which has significance for serum chromium levels. None of our patients had signs of corrosion, pseudoarthrosis or rod breakage on radiological examination. Compared to raised serum chromium levels, the number of metal-onmetal interfaces approached significance (p = 0.09). Individual numbers of screws, hooks, cables or cross-connectors were not significantly associated with chromium levels. Conclusions: Total rod length may contribute to elevated chromium levels in patients with stainless steel Isola spinal implants and warrants further investigation

Purpose: The current gold standard for spinal arthrodesis, autologous bone graft harvested from the iliac crest, has several disadvantages including donor site morbidity, blood loss, delayed wound healing, and increased operative time. Our study explores a Demineralized Bone Matrix-Calcium Sulfate(DBM-CaSO4) composite graft with autologous bone marrow aspirate (BMA), and compares it to autologous iliac crest bone graft in lumbar and lumbosacral spinal fusions. Method: A total of 80 patients were recruited for the study and randomised, via a computer-generated ran-domisation schedule, to autologous iliac crest bone graft (control) or DBM-CaSO4 composite graft with BMA (study) groups. Patients were evaluated at three-months, six-months, 12-months and 24-months post-operatively with questionnaires to evaluate clinical outcome (Oswestry disability questionnaire (ODI), visual analogue pain scales (VAS), and validated SF-36) and with posteroanterior and lateral x-rays of the spine to evaluate radiological outcome. Results: At 24-months post-operatively, there were no statistical differences seen between the two groups based on the clinical outcomes measured. Average ODI values were 27.19 for the control group versus 22.68 for the study group (p > 0.05). The average back VAS pain for the control group was 3.50 versus 3.51 for the study group (p > 0.05). The SF-36 score was 89.22 for the control group versus 91.56 for the study group (p > 0.05). The average operative time was 115.7 minutes for the control group versus 104.2 minutes for the study group (p: 0.014). Average calculated blood loss was 571.9 cc for the control group versus 438.2 cc for the study group (p: 0.025). The Lenke score was 1.92 for the control group versus 2.66 for the study group (p: 0.004). Conclusion: At two year follow-up, radiographic fusion was slightly higher in the ICBG. However, clinical outcomes were equivalent in both groups. Moreover, the DBM-CaSO4 and BMA composite graft offered the advantages of decreased blood loss and shorter operative time. Therefore, the DBM-CaSO4 and BMA composite graft represents a viable alternative to autologous iliac crest bone graft in carefully selected patients undergoing spinal arthrodesis

Purpose of the study. We report septic shock as postoperative complication following an instrumented posterior spinal arthrodesis on a patient with multiple body piercings. The management of this potentially catastrophic complication and outcome of treatment is been discussed. Summary of Background Data. Body piercing has become increasingly more common due to change in culture or as a fashion statement. This has been associated with local or generalized ill effects including tissue injury, skin and systemic infections, and septic shock. There is no clear guideline pathway regarding removal and reinsertion of body piercings in patients who undergo major surgery. Complications following Orthopaedic or Spinal procedures associated with body piercing have not been reported. Methods. We reviewed the medical notes and radiographs of an adolescent patient with severe Scheuermann's kyphosis and multiple body piercings who underwent an uneventful posterior spinal arthrodesis with pedicle hook/screw/rod instrumentation and autologous iliac crest bone graft and developed septic shock. Results. Septic shock developed on postoperative day 2 after reinsertion of all piercings following patient's request. The patient became systemically very unwell and required intensive medical management, as well as a total course of antibiotics of 3 months. The piercings remained in situ. She did not develop a wound infection despite the presence of bacteraemia (coagulase-negative Staphylococci/Streptococci warneri) and spinal instrumentation. The patient had no new piercings subsequent to her deformity procedure. Two and a half years after spinal surgery she reported no medical problems, had a balanced spine with no loss of kyphosis correction and no evidence of nonunion or recurrence of deformity. Conclusion. The development of septic shock as a result of piercing reinsertion in the postoperative period has not been previously reported. This is an important consideration to prevent potentially life-threatening complications following major spinal surgery. Despite the wide array of complications associated to body art there are no clear guidelines for body piercing. There is growing public awareness and several countries are laying regulations which have not yet been internationally standardized. A clear practice guideline in the perioperative management of piercings is needed as the incidence of body piercing and associated complications is rising. There is need for surgeons to be aware of the hazards of body piercing and its implications. We propose that multiple piercings should not be reinserted after major surgery and appropriate counseling should be provided to the patients as part of the consent process

Summary of Background Data. Obstruction of the third part of the duodenum by the superior mesenteric artery (SMA) is associated with spinal manipulation in the surgical or conservative management of scoliosis. Purpose of the study. The aim of the present study was to investigate the prevalence of SMA syndrome in a cohort of 165 consecutive pediatric patients who underwent spine deformity surgery and had minimum 2-year follow-up. Material-Methods. The study group comprised 85 patients with idiopathic scoliosis, 20 patients with neuromuscular and 18 patients with miscellaneous or syndromic scoliosis, and 42 patients with congenital spinal deformities. Posterior spinal arthrodesis was performed in 94 patients, combined anterior/posterior in 60 patients, and anterior spinal fusion in 11 patients. Results. We identified 4 patients who developed SMA syndrome postoperatively. These were all markedly underweight, adolescent females; 2 patients had adolescent idiopathic scoliosis, one had neuromuscular, and one congenital scoliosis. Third generation instrumentation systems with derotational effect were used in 3 patients. The spinal arthrodesis in the patient with neuromuscular scoliosis was performed using bone graft followed by application of a spinal jacket. The symptoms developed at a mean of 3.7 days post-surgery and included nausea, vomiting, increased nasogastric aspirates, abdominal pain and distension. Conservative management with prolonged nasojejunal feedings achieved resolution of the symptoms in all but one patient, who required derotation of the duodenum and jejunum. There was no evidence of recurrence of the condition in any patient at the latest follow-up. Conclusions. The prevalence of SMA syndrome in our series was 2.4%. This draws attention to the significance of prevention of the condition by recognizing patients who are at a higher risk. An early diagnosis of the syndrome will allow for application of conservative methods and will increase the chances for a successful outcome

Purpose of the study. To investigate the efficacy of pedicle screw instrumentation in correcting spinal deformity in patients with quadriplegic cerebral palsy. Also to assess quality of life and functional improvement after deformity correction as perceived by the parents of our patients. Summary of Background Data. All pedicle screw constructs have been commonly used to correct adolescent idiopathic scoliosis. There is limited information on their effectiveness in treating patients with cerebral palsy and neuromuscular scoliosis. Methods. We reviewed the medical records and serial radiographs of 45 consecutive patients with quadriplegia who underwent spinal arthrodesis using pedicle screw/rod instrumentation and a standardised surgical technique (prospectively collected single surgeon's series). All patients were wheelchair bound with collapsing thoracolumbar scoliosis and pelvic obliquity. Twenty-eight patients had associated sagittal deformities. A telephone survey was performed by an independent investigator to assess parents' perception on surgical outcome. Results. Thirty-eight patients underwent posterior-only and 7 staged anteroposterior spinal arthrodesis. Mean age at surgery was 13.4 years (range 9-18.3) and mean postoperative follow-up 3.5 years (range 2.8-5). Pedicle screw instrumentation extended from T2/T3 to L5 with bilateral pelvic fixation using iliac bolts. Scoliosis was corrected from mean 82.5° to 21.4° (74.1%). Pelvic obliquity was corrected from mean 24° to 4° (83.3%). In posterior-only procedures, average blood loss was 0.8 blood volumes, ICU stay 3.5 days, and hospital stay 17.6 days. In anteroposterior procedures, average blood loss was 0.9 blood volumes, ICU stay 8.9 days, and hospital stay 27.4 days. Major complications included one deep infection and one re-operation to remove prominent implants but no deaths, no neurological deficit and no detected pseudarthrosis. Parents' survey demonstrated 100% satisfaction rate. Conclusion. Pedicle screw instrumentation can achieve excellent correction of spinopelvic deformity in quadriplegic cerebral palsy with low complication and re-operation rates and high parent satisfaction. Our study has demonstrated that spinal correction using segmental pedicle screw/rod constructs can be performed safely and with lesser major complications and reoperations compared to the traditionally used Unit rod or hybrid instrumentation. The greater degree of deformity correction and lesser rate of complications and reoperations due to non-union, prominent instrumentation or failed pelvic fixation using a pedicle screw compared to the Unit rod technique should be balanced against the increased implant cost

Autograft – Since before modern surgical techniques were described, ancient Greeks new of the possibilities for bone to grow after fracture. Studying open fractures, often post mortem, they new of the importance of both the “amount and integrity of bone architecture” that was necessary for two ends of a bone to heal. More recently, modern spinal surgical techniques, many pioneered by surgeons such as John Moe MD, use the same knowledge that for the intentional arthrodesis of two or more bony spinal levels there requires a certain amount and quality of bone – both capturing osteoinductive and osteoconductive properties. Autograft can be harvested in many ways for spinal arthrodesis and can be taken from iliac crest, tibia or fibula, and from local vertebral sources. Often requiring a separate skin and/or fascial incision, morbidities such as pain, neurovascular injury, infection, blood loss, haematoma, seroma, and fracture can plague the technique. Limited quantities, especially in children, can also be an issue with autograft. Cancellous or cortico-cancellous structural grafts can be milled and used for posterolateral fusion, interbody fusion, and can be mixed with other graft substitutes/expanders. Morbidity profile aside, autograft still remains the gold standard for spinal arthrodesis with regards “ideal properties” of bone grafts. Allograft – Currently, allograft is the most common substitute for autograft bone in spinal fusion. Allograft is primarily osteoconductive, with minimal osteoinductive potential. Avoidance of donor site morbidity, quantity issues, and surgical time saving are all features of allograft. Increased costs and potential for infection are negative issues. Preparation can vary and fresh unprocessed grafts are no longer used. Freeze drying (lyophilization) involves drying of the grafts before freezing at sub zero temperatures, and the technique reduces immunogenicity, though upon rehydration, structural strength is lost by around 50%. Low dose radiation (< 20kGy) can also be used to process the grafts, as can ethylene oxide, yet both techniques also reduce mechanical strength of the trabecular architecture. With adequate donor screening and tissue processing, the risk of developing HIV from an allograft is estimated to be less than 1 in a million. Incorporation of allograft is similar to that of autograft, though the process takes more time. Allograft cancellous particles provide a larger surface area and therefore incorporate faster. Studies suggest that mulched allograft femoral heads provides as good a fusion rate in posterior spinal surgeries for children with scoliosis as does the use of autograft. Combination of osteoinductive agents (BMP etc) with allograft is now possible and will likely enhance its further use. Structural fibular allografts in cervical interbody fusion and femoral ring allografts in lumbar interbody fusion have been well described and have very high rates of fusion