Purpose: To evaluate the long term clinical outcomes as well as radiological changes in distal unfused mobile segments and to evaluate factors that may predispose to distal disc degeneration and/or poor outcome.

Method: 151 mobile segments in 85 patients (65 female), mean age 43.2 (range 21–68), were studied. Curve type, number of fused levels and pelvic incidence were recorded. Clinical outcome was measured using the Whitecloud function scale and disc degeneration using the UCLA disc degeneration score. Spinal balance, local segmental angulations and lumbar lordosis were measured pre- and post-operatively as well as at the most recent follow up – mean 9.3 years (range 7–19).

Results: 62% of patients had a good or excellent outcome. 11 had a poor outcome of which 10 underwent extension of fusion – 5 for pain alone, 3 pain with stenosis and 2 pseudarthroses. Pre-operative disc degeneration was often asymmetric and was slightly greater in older patients. Overall, there was a significant deterioration in disc degeneration (p< 0.0001) that did not correlate with clinical outcome. Disc degeneration correlated with the recent sagittal balance (Anova F=14.285, p< 0.001) and the most recent lordosis (Anova F=4.057, p=0.048). The post-operative sagittal balance and local L5-S1 sagittal angulation correlated to L4 and L5 degeneration respectively. There was no correlation between degeneration and age, pre-operative degenerative score, pelvic incidence, sacral slope, number of fused levels or distal level of fusion.

Conclusion: Disc degeneration does occur below an arthrodesis for scoliosis in adults which does not correlate with clinical outcome. The correlation of loss of sagittal balance with disc degeneration may be as a result of degeneration causing the loss of balance or vice versa i.e. sagittal imbalance causing degeneration. Immediate post-operative imbalance correlates with degeneration of the L4/5 disc, which may imply the latter.

Purpose: To evaluate the indications, outcome, risk factors and complications of transpedicular osteotomy (TPO) in revision scoliosis surgery

Methods: We evaluated patients undergoing TPO for revision scoliosis surgery at our institution between 1989 and 2004 with a minimum follow up of 18 months. Demographic data, anaesthetic risk factors, peri-operative data and complications were recorded. Radiographs pre-operatively, post-operatively and at last follow up recorded sagittal balance, coronal balance, lumbar lordosis and pelvic parameters. Functional outcome was measured using the Whitecloud score.

Results: 21 patients (24 TPO’s) mean age 48.7 years with mean follow up 4.4 years fulfilled criteria for study. All cases had fixed sagittal imbalance pre-operatively. Mean operative time was 4.6 hours and mean transfusion requirement was 2.3. units. A significant improvement (p< 0.03) in sagittal imbalance was gained (although in 3 cases of pseudarthroses this was partially lost) and the post-operative lumbar lordosis correlated closely significantly pelvic incidence (p< 0.03). Functional outcome was good/excellent in 67% cases.

We report 28 complications. 22 early included 4 dural tears, cardiac decompensation with reduction, 5 neurological deficits including a parpaplegia secondary to haematoma which was evacuated and the patient made a good recovery at 6 months, 2 UTIs, IVI infection, superficial wound infection and extension of metalwork due to early proximal decompensation. Late complications included infection (8 years), removal of prominent metalwork, radiculopathy due to screw (6 months) and 3 pseudarthroses. There was no statistically significant correlation of complication with weight, ASA grade or smoking.

Conclusion: TPO in revision scoliosis is an effective method of correcting both coronal and sagittal imbalance but is not without complication, although good functional outcome is achieved in most patients. It is important to consider pelvic parameters pre-operatively to plan the level and magnitude of TPO required.

Study Design: Retrospective chart review.

Objective: To assess the pulmonary function and rib deformity of patients following Schollner and modified Schollner costoplasty. Little is described in the literature concerning the long term effects of costoplasty.

Methods: Retrospective analysis of patients undergoing costoplasty at our institution with a minimum of three year and a maximum of 22 years follow-up.

Subjects: 23 (20 female) patients with a primary diagnosis of late-onset idiopathic scoliosis with a rib hump deformity underwent costoplasty at age 25 (16–36). 10 had surgery on the convexity alone and 13 had additional ‘concave surgery’ (6 of these had silastic implants). 3 patients had simultaneous correction of spinal deformity and costoplasty. The remainder underwent delayed procedures (0.6–19 years) following the index operation. Harrington instrumentation was used in all patients for primary curve correction.

Outcome measures: Forced Vital Capacity (FVC) – including % normal expected for age and rib hump (clinically and from radiographs) were measured pre and post-operatively at each attendance to assess the outcome of the procedure.

Results: The mean follow up was 10.7 years (3–22). Average reduction in rib hump was 33 mm at 6 months and 25 mm at the latest follow-up. There was no significant difference in the pre-operative and long-term FVC (p=0.4, paired t-test), although 6 months post-operatively there was a significant reduction in FVC (p=0.03, paired t-test). Subgroup analysis (convex only, convex/concave without silastic implant, convex/concave with silastic implant) revealed a similar pattern for rib hump correction and maintenance of FVC in all 3 groups at latest follow-up. However for patients undergoing convex surgery alone, the difference between FVC at 6 months and at latest follow-up was significant (p=0.01, paired t-test).

Conclusions: Rib hump correction and lung function (even accounting for age) are preserved in the long term following costoplasty. This study does not show any benefit of additional surgery on the concavity of the curve in reducing the rib hump on the convexity or on the FVC.

We have evaluated the use of a synthetic porous ceramic (Triosite) as a substitute for bone graft in posterior spinal fusion for idiopathic scoliosis. In a prospective, randomised study 341 patients at five hospitals in the UK and France were randomly allocated either to autograft from the iliac crest or rib segments (171) or to receive Triosite blocks (170). All patients were assessed after operation and at 3, 6, 12 and 18 months.

The two groups were similar with regard to all demographic and baseline variables, but the 184 treated in France (54%) had Cotrel-Dubouset instrumentation and the 157 treated in the UK usually had Harrington-Luque implants. In the Triosite group the average Cobb angle of the upper curve was 56°, corrected to 24° (57%). At 18 months, the average was 26° (3% loss). In the autograft group the average preoperative upper curve of 53° was corrected to 21° (60%). At 18 months the mean curve was 25° (8% loss). Pain levels after operation were similar in the two groups, being mild in most cases. In the Triosite group only three patients had problems of wound healing, but in the autograft group, 14 patients had delayed healing, infection or haematoma in the spinal wound. In addition, 15 autograft patients had pain at the donor site at three months. Seven had infections, two had haematoma and four had delayed healing.

The haematological and serum biochemistry results showed no abnormal trends and no significant differences between the groups. There were no adverse events related to the graft material and no evidence of allergenicity.

Our results suggest that Triosite synthetic porous ceramic is a safe and effective substitute for autograft in these patients. Histological findings on biopsy indicate that Triosite provides a favourable scaffolding for the formation of new bone and is gradually incorporated into the fusion mass.

The results of surgery in 59 patients with Scheuermann's kyphosis are reported at an average follow-up of 56 months. These show that in skeletally immature patients, in whom the iliac apophysis has not yet fused to the body of the ilium, posterior fusion alone is adequate and is followed by little loss of correction. For skeletally mature patients combined anterior and posterior surgery is recommended. In all cases a period of pre-operative treatment is important. It is stressed that the indications for surgery are limited.