Background: To assess the clinical and radiological results of motion-segment sparing anterior cervical partial discectomy and foraminotomy surgery in patients with at least 1 year of follow-up.

Methods: The study is a prospective, non-randomized, observational study. The patients all had symptoms of intrusive nerve root irritation with or without motor symptoms, refractory to conservative management for greater than 6 weeks duration. Patients were asked to complete questionnaires capturing) VAS (visual analogue) pain scores, NDI (neck disability index) and European myelopathy scores, patient satisfaction, and return to work details. Radiographic assessments were collected preoperatively, at 4 weeks, 3 months, 6 months, 1 and 2 years postoperatively.

Results: 58 patients have been assessed with at least 1year follow-up. The mean duration of symptoms prior to surgery was 24 weeks (6–20 weeks). 55 patients had single level surgeries (C5/C6-15, C6/C7-38, C7-T1-2), 3 patients had two level surgeries (C4/C5& C5/C6-1, C5/C6& C6/C7-2). In 34 patients sugery was for soft disc prolapse, in 12 patients surgery was for hard osteophytes and in 12 patients both pathologies contributed equally. Operation time ranged from 50–85 minutes. Average in patient stay was 2.6 days. There were no complications apart from 1 patient who had to return early to theatre for evacuation of haematoma and then made a full recovery. All patients reported pain intensity reductions. Pain decreased from 6.7 to 1.4 for arm pain on a 10-point scale. NDI scores improved from a preop mean of 42 to 16 on a 100 point score at 6 months post-surgery. All patients returned to their usual occupations with the exception of 2 patients who are involved in litigation against an employer or third party. No patient required repeat surgeries. Radiographic analysis at 1 year shows preservation of segmental motion in 75% patients, preservation of interbody height in 60% patients, spontaneous fusion in 12% patients.

Conclusion: A clinical success rate of 90% was achieved (clinical success being defined as a patient rating of very satisfied or satisfied on a 5-point patient self-scoring outcome scale). 56 out of 58 patients would undergo the same procedure again and recommend it to friend.

Background: A novel, elastomeric total cervical disc replacement is currently undergoing clinical evaluation in an MHRA approved Multicentre European study. At the time of abstract submission seven patients have been implanted with the device. The device is a two component one consisting of an inner core of medical grade silastic enveloped in an outer jacket of embroidered polyester that replicates the annulus, posterior and anterior longitudinal ligaments.

Methods: The pre-clinical testing of the device included biomechanical, biocompatibility and mechanical fatigue testing have previously been reported at the 2002 Spine Arthroplasty Society meeting in Montpellier. At the time of abstract submission seven patients have been implanted with the device. The clinical trial is a prospective, non-randomized observational study. Patients are followed for a period of two years. VAS pain scores, SF36, NDI and European myelopathy scores, patient satisfaction and detailed radiographic assessments are collected preoperatively, at 4 weeks, 3 months, 6 months, 1 and 2 years postoperatively.

Results: Seven patients (2 female, 5 male) have been implanted at the time of abstract submission. All cases were single level surgeries (C3/C4-1, C5/C6-2, C6/C7-4). Operation time ranged from 55-104 minutes. Blood loss averaged less than 15mls. The NeoDisc implant is very straightforward to implant with no special instrumentation. The lack of any metal components has allowed postoperative MRI and CT scanning to be performed with virtually no artefact present and excellent visualisation of cord and root detail. All patients reported pain intensity reductions. Pain decreased from 4.6 to 1.4 for neck pain and from 6.5 to 0.9 for arm pain on a 10-point scale.

Conclusion: A clinical success rate of 83% was achieved (clinical success being defined as a patient rating of excellent or very good on a 6-point patient self-scoring outcome scale).

Study Design: A retrospective review of case notes and histology reports.

Summary of Background Data: Up to 8% of cancer patients develop second malignancies. The vertebral column is frequently involved in metastatic disease and may represent the first manifestation of malignancy in up to 40% of patients. The rate of vertebral metastasis from a second tumour in patients with a known primary is not well known.

Objective: We sought to identify the incidence of a second primary in patients referred to our unit with spinal malignancy and a previously diagnosed primary tumour.

Subjects: 222 patients underwent definitive surgery for spinal metastatic disease of whom 135 had a prior history of malignancy.

Outcome measures: Histological tissue of origin of spinal metastasis in light of previous known malignancy.

Results: In 16 patients (11.9%) the vertebral histology differed from the initial primary. The period between first and second malignancies varied widely (19 months – 22 years). Thirteen patients (9.6%) had identifiable tissue origins for the metastasis that was not in keeping with the previous malignancy. Three further patients showed sufficient histological and imunohistochemical differences such that a further tumour of unknown origin and not de-differentiation of the previous tumour was suspected. Three previously unrecognised tumours were diagnosed on biopsy and eight on tissue obtained at definitive surgery.

Conclusion: The incidence of second primaries, in particular myeloma, presenting with vertebral metastases is significant and should always be borne in mind when assessing patients and planning treatment. Biopsy should be performed when possible. Comparison needs to be made between the histological features of the previous primary and metastasis.

We conducted a prospective, randomised study of 42 cervical interbody fusions undertaken with either an autologous tricortical graft or a cage. The factors assessed in the two groups were: (1) time taken to achieve fusion; (2) neck disability index; (3) pain score; (4) interbody height ratio; (5) interbody angle and (6) the influence of smoking on fusion.

No statistical difference was seen in the time taken to achieve fusion, neck disability index, interbody height ratio, or interbody angles. Smoking did not have any effect on the fusion process. The pain score was significantly lower in the tricortical graft group at six months. We conclude that both methods of fusion give similar results, although tricortical graft fusion is cheaper than cage fusion, and is more effective in reducing the pain score.

14 systems for anterior cervical stabilisation were evaluate under flexion-compression bending using test procedures conforming to Static and Fatigue Test Methods for Spinal Implant Assemblies using Corpectomy Models Part 2a [ISO/TC 150/SC5 N127C]

Plates of standardised active length were tested in an in-vitro model of a single corpectomy of the lower cervical spine using composite test blocks manufactured by Sawbones to have physical properties similar to cervical vertebrae.

Results reveal a wide range in final yield strengths with bi-cortical systems significantly stronger than uni-cortical ones. There was a fourfold difference in ultimate load between the stronger and weakest systems.

We found that mode of failure was influenced by plate thickness, screw length and screw placement.

The purpose of this retrospective study was to analyze the indications for spinal instrumentation, report the clinical features, operative details and outcome in 16 patients with active pyogenic spinal infection.

Between January 1991 to October 1999, 81 patients with spontaneous pyogenic spinal infection were treated at the authors’ institution. Surgery (other than biopsy) was indicated in 24 patients for neurological deterioration, deformity or instability. Sixteen of these patients were treated with instrumentation in the presence of active spinal infection. Six patients underwent combined anterior and posterior procedures. 10 had a posterior procedure only. Outcomes assessed were control of infection, neurology, fusion, back pain and complications.

At a mean follow up period of 26. 9 months, all surviving patients were free of clinical infection. None of the patients had neurological deterioration. All patients who had neurological deficit preoperatively improved by at least one Frankel grade. A solid fusion was achieved in 15 patients. 12/15 patients remained asymptomatic or had very little pain. The remaining 3 patients had mild to moderate back pain. The mean correction of the kyphotic deformity was 18. 92 degrees. Postoperative complications included bronchopneumonia, nonfatal pulmonary embolism and seizures in 3 patients. One patient developed progressive kyphosis despite instrumentation but eventually fused in kyphus.

Given early recognition of pyogenic spinal infection, most cases can be managed non-operatively. Our results support that instrumented fusion with or without decompression may be used safely when indicated without the risk of recurrence of infection. Instrumentation facilitates nursing care and allows early mobilisation. For biomechanical reasons, a combined procedure is probably indicated for lesions above the conus. For lesions below the conus, we were able to achieve successful results with posterior approach only.

In the 40 years since Smith and Robinson described the anterior approach to decompress and fuse the cervical spine, generally acceptable clinical results have been reported though few papers include any form of detailed outcome assessment. More recently Snyder and Bernhardt have described an anterolateral disc-preserving approach to treat cervical radiculopathy that does not entail vertebral artery exposure. We describe our experience of this procedure.

Surgery was performed on 40 patients ( 21 male, 19 female, mean age 41 years). Functional outcome was assessed by the Neck Disability Index (NDI), return to usual work status, patient subjective satisfaction rating, and by standard VAS. Radiographic evaluation was performed looking at the following parameters: neutral films – maintenance of interbody disc height/diameter ratio R and degree of kyphosis/lordosis: dynamic films – degree of movement maintained at operated motion segment.

At an average follow up of 20 months(range 6 – 36) the mean NDI had fallen from 45% to 10% .Mean neck pain score was 2 (pre op was 7), average arm pain score 1 (pre op was7). 93% of patients had returned to work, 85% to their original occupation at an average of 11 weeks. Patient satisfaction scores were: 85% very satisfied, 5 % satisfied, 5% unsatisfied and 5% very unsatisfied. Radiologically it was possible to preserve intervertebral body disc height and motion in some patients whilst others lost some height and motion. A minority fused spontaneously.

ACFID is associated with clinical functional outcome scores comparable with those reported in the literature for alternative procedures. Bone graft donor site morbidity is avoided and radiological results show that preservation of useful motion at the operated disc is possible.

Objective: To assess the validity of the Tokuhashi and Tomita scoring systems in the prediction of prognosis following spinal surgery for skeletal metastases.

Design: A retrospective cohort study of patients treated in a specialist spinal unit

Subjects: All patients undergoing definitive surgery for metastastes of the spine were considered eligible. Time to death or current length of survival was available in 147* of these which was confirmed by the Cancer Registry. Medical and nursing case notes were reviewed and prognostic scores using the methods of Tokuhashi et al, and Tomita et al. were calculated for each patient.

*

death data for further patients currently awaited from Cancer Registry.

Outcome measures: Mean survival period with 95% confidence intervals for patients grouped according to prognostic score.

Results: Thirty-two patients were still alive and 113 had confirmed death dates. Forty-three patients had Tokuhashi scores of 9 or greater with a mean survival of 20.1 months (95% confidence interval 5.8 months) compared to 9.5 months (2.9 months) for scores 6–8 and 3.5 months (1.8 months) for scores below this. Tomita scoring showed a similar trend with those with better prognostic profiles but without the same degree of statistical significance. The overall 30-day mortality was 8.2% with no significant difference between any other groups.

Conclusion: In patients presenting with metastatic disease involving the spine, published prognostic profiles offer some guidance to likely survival of the patient and so the appropriateness of surgical treatment.

The Synex cage is an expanding titanium implant designed for reconstruction of the anterior column in injury, post-traumatic kyphosis or tumour of the thoracolumbar spine. It is supplemented by a stabilizing implant. As it is expandable in situ it therefore can be inserted via a relatively small exposure. The design enables good purchase of the endplates and reduces the possibility of secondary displacement.

Surgery for anterior reconstruction is usually performed via an anterior approach, however, there are incidences were a posterolateral approach is indicated. The Synex cage is useful in these circumstances, as being expandable, posterolateral insertion with preservation of the nerve roots is possible. The Synex cage is then supplemented with a posterior construct. The cage can be inserted via a left or right posterolateral approach. A specially designed angled screwdriver is now available to release the ratchet mechanism and if necessary collapse the cage.

We present, what is, to the best of our knowledge and that of the manufacturer, the first two patients where a Synex cage has been inserted using the posterolateral approach.

Conclusion: Synex cage has the advantage of being expandable and it is therefore possible to insert this via a potentially small exposure, between the nerve roots, using a posterolateral approach

Objective: To compare fusion time, Neck Disability scores, Pain scores, interbody height ratio and angulation, in cervical interbody fusion performed using tricortical graft or Ostapek cage, and a comparison between smokers and non smokers in fusion times.

Design: A prospective randomised study.

Subjects: Forty-two patients aged between 30 and 71years. Eighteen tricortical graft fusions, and 24 Ostapek cage fusions.

Outcome measures: Grading of fusion from plain radiographs, Neck Disability Scores, Pain scores, interbody height ratio, and interbody angulation.

Results: Mean time to good quality fusion was 4.66 months in the cage group and 5.97 months in the tri-cortical graft group with p< 0.5 and 5.00 months in the smoking population and 5.6 months in the non-smoking population with p< 0.5. At six months: mean percent NDI was 66.75 in the cage group and 50.67 in the tri-cortical graft group 0.1< p< 0.5;mean percent pain scores were 70.33 in the cage group and 34.50 in the tricortical graft group 0.02< p< 0.05; mean percent interbody height ratio was 98.68 in the cage group and 95.22 in the tricortical graft group 0.1< p< 0.5; mean change in interbody angle was 1.36° kyphosis in the cage group and 3.8° of kyphosis in the tricortical graft group 0.05< p< 0.1.

Conclusions: Tricortical graft fusion gives equal results to cage fusion and is much cheaper.

Objective: We present our recent experience in the management of tumours of the cervical spine and in particular comparing patterns of presentation of benign and malignant tumours and highlighting any delays of treatment.

Design: A retrospective study of 40 patients treated operatively at a regional spinal centre between 1995 and 2001.

Results: Twenty-five patients had metastastic disease and fifteen had primary tumours, five of which were malignant. Patients with malignant disease were older at diagnosis (55 vs 40) and had a shorter duration of symptoms (3m vs 19m). All patients with metastases reported good pain relief and improvement in neurological function where myelopathy or radiculopathy was present. Eight of these twenty-five patients have died at a mean of eleven months postoperatively. The longest survivor is now 31 months surgery. There were some excessive delays in treatment in benign and malignant cases. There were five cases of missed or wrong diagnosis and three patients waited more than six months for investigations.

Conclusions: Surgery for metastatic disease in the cervical spine has been successful in improving the quality of life in all of the patients although it should be stressed that each case must be dealt with on an individual basis with a multidisciplinary approach. It was noteworthy that some patients were subjected to extraordinary delays in diagnosis.