Introduction

The placement of a large interbody implant allows for a larger surface area for fusion, vis a vis, via retroperitoneal direct anterior, antero-lateral and lateral approaches. At the same time, spinal navigation facilitates a minimally invasive fixation for inserting posterior pedicle screws. We report on the first procedures in the United Kingdom performed by a single-surgeon at a single- centre using navigated robot-assisted spine surgery without the need for guide-wires.

Aims

In the United Kingdom, lower incidences of intraspinal abnormalities in patients with early onset idiopathic scoliosis have been observed than in studies in other countries. We aimed to determine the rates of these abnormalities in United Kingdom patients diagnosed with idiopathic scoliosis before the age of 11 years.

Twenty-three patients with thirty hips of slipped capital femoral epiphysis were treated in our department, KK Women's and Children's Hospital, Singapore between 1997 and 2005. Except one patient lost of follow-up, twenty-four SCFEs with more than 2 years (25 to 73 months, average 38.5 months) follow-up were reviewed. This study is to evaluate the effectiveness and outcome of our protocol: Russell traction followed by gentle manipulative reduction with a single screw fixation & spica cast immobilization (for acute-on-chronic cases with unstable and reducible SCFE). In this series, there were 13 boys & 5 girls, mean age 12 year old ranging from 10 to 14 years. Among them 7 were Chinese, 6 Malays & 5 Indians. There were 12 unilateral cases (8 on the left & 4 right, 67%) & 6 bilateral cases (33%), including 2 patients found contralateral SCFE subsequently 1 year postoperatively. Acute-on-chronic SCFE were 16 & chronic SCFE 8. 16 were Grate I & 8 Grate II. Russell traction was on preoperatively with an average of 6 days. Gentle manipulative reduction under general anesthesia was performed in 20 SCFEs (12 GI & 8 GII) and 17 of them were successful. Fixation with a single screw was used for all cases except one hip with 2 screws. Average follow-up was 38.5 months. Good results achieved. All patient were symptom free with good function. No complications of AVN, chondrolysis, screw loosening and reslipping of the affective hips. Our protocol of management for SCFE has been largely successful in term of manipulative reduction and fixation.

Study Design: Retrospective case series.

Objective: To evaluate the clinical outcome, radiographic results and complications associated with single rod anterior instrumentation in neuromuscular thoracolumbar scoliosis.

Methods: Retrospective study with mean follow up of 35 months.

Subjects: Nine patients (6F, 3M), mean age 15 years, were operated on between 1994–2000. This heterogeneous patient group consisted of five cases of spinal dysraphism, one prune belly syndrome, one arthrogryposis, one myotonic dystrophy and one congenital myopathic dystrophy (muscle-eye-brain-syndrome). All patients were ambulatory and had minimal pelvic obliquity (< 15degrees).

Outcome measures: Pre-operative, post-operative and final follow-up measurements of Cobb angles, apical vertebral translation (AVT), thoracic kyphosis, lumbar lordosis, sagittal and coronal balance were recorded along with operative complications, pseudarthrosis, metalwork failure and loss of correction.

Results: There was one rod breakage and one case of proximal thoracic curve progression requiring supplementary posterior surgery. For the remaining 7 patients, the average corrections for Cobb angle was 62% (52 to 20 degrees), AVT was 53% (5.7 to 2.7cms), and both thoracic kyphosis and lumbar lordosis remained unchanged. No pseudarthrosis, vascular or neurological complications were encountered. Subjectively results were excellent in six and good in one.

Conclusions: Selective anterior instrumentation for neuromuscular scoliosis using a single rod resulted in acceptable clinical and radiographic outcomes in this highly selected series. Advantages include preservation of distal lumbar motion segments whilst maintaining sagittal and coronal alignment. We believe that this method of scoliosis correction has a definite yet select role in patients who are ambulatory, have minimal pelvic obliquity (< 15degrees), non-progressive pathology and near normal mental function.

Objective: To evaluate the subjective clinical outcomes, radiographic results and complications associated with single solid rod anterior instrumentation in neuromuscular scoliosis.

Design: Retrospective clinical case series with a mean follow up of 30 months (range 24 – 42 months).

Subjects: 9 consecutive cases (6F, 3M) with a mean age 15 years (range 11 – 24 years), underwent single solid rod anterior instrumentation of their neuromuscular thoracolumbar scoliosis between 1994 and 2000. The heterogeneous patient group consisted of 5 spinal dysraphism, and 1 each of prune belly syndrome, arthrogryposis, myotonic dystrophy and congenital myopathic dystrophy (muscle eye brain syndrome). All patients were ambulatory and had minimal pelvic obliquity (< 15 degrees).

Outcome measures: Pre-operative, post-operative and final follow up measurements were collected for 1) Cobb angles, 2) apical vertebral translation (AVT), 3) thoracic kyphosis (T5-12) and 4) lumbar lordosis (L1-5). Operative complications, pseudarthrosis, metalwork failure and loss of correction were also recorded.

Results: There was 1 each of rod breakage and upper thoracic curve progression requiring supplementary posterior surgery. For the remaining 7 patients, the average follow-up corrections for Cobb angle was 56% (49 to 22 degrees), AVT was 49% (5.1 to 2.6 cms), and both the thoracic kyphosis and lumbar lordosis remained unchanged. No significant loss in correction occurred during the post-operative period to final follow-up in all the above parameters. No pseudarthrosis, vascular or neurological complications were encountered. Subjectively, there were 6 excellent and 1 good results.

Conclusions: In this limited case review, selective anterior instrumentation for neuromuscular scoliosis using a single solid rod system resulted in acceptable clinical and radiographic outcomes. Our results appear to compare favourably with those published for the recommended method of posterior instrumentation. Advantages include preservation of distal lumbar motion segments whilst maintaining segmental saggital and coronal alignment. We believe that this method of scoliosis correction has a definite yet select role in patients who are ambulatory, have minimal pelvic obliquity (< 15 degrees), non-progressive pathology and near normal mental function.

We present a case of fatal ‘malignant’ necrotising streptococcal myositis in a previously healthy 39-year-old man. The infection was caused by Lancefield group-A haemolytic streptococcus (Streptococcus pyogenes). This case highlights the clinical features and the necessity of prompt aggressive treatment.

Between 1993 and 1998, 16 consecutive hips in 12 patients (3M, 9F) with a mean age of 22 yrs (14–38 yrs), and mean time of symptom onset from surgery of 35 mths (9–60 mths) underwent Z-plasty of the iliotibial band for snapping hip. At mean follow-up of 36 mths (15–60 mths), all 16 hips (12 patients) were free of snapping whilst 14 hips (11 patients) experienced complete relief of symptoms. All patients considered the procedure successful and worthwhile, and there were no complications. We conclude that, in select patients who experience painful snapping of the hip because of a tense iliotibial band that has failed non-operative measures, iliotibial band lengthening by Z-plasty has been successful at improving or completely abolishing hip pain and snapping.

We analysed the functional outcome (Oswestry Disability Index) after technically and radiologically successful lumbar fusion in 39 non-compensation seeking patients with chronic low back pain, who had a High Intensity Zone (HIZ) – positive MRI and subsequently underwent discography. The average follow-up was 33 months. The HIZ-positive, discogrampositive group was the only one with statistically significant improvement. The HIZ-positive, discogram-negative group had the worst outcome. Relying only on the HIZ fails to identify the group of patients who would have had negative discography at the same levels. Therefore the presence of HIZ alone should not dictate treatment plan without discography confirmation.

In a prospective non-randomised study, 28 patients underwent laparoscopic assisted transperitoneal anterior interbody fusion at the lumbosacral junction with the BAK cage over a 3-year period. In laparoscopic group, there were significantly lower blood losses (P< 0. 005), operating times [P< 0. 05], analgesic requirements [P< 0. 05] and postoperative rehabilitation [P< 0. 05). 8 patients developed post-operative nerve root pain, 5 of which settled with nerve root blocks, and there was 1 case of donor site infection. Intraoperative complications included 1 CIA tear, 2 CIV tears and 3 open conversions [11%]. 6 cases [24%] required further surgery at a mean of 14 months [range 4–29 months]. 20 laparoscopic cases completed a subjective self-assessment score with 4 [20%] excellent results, 5 [25%] good, 2 [10%] fair, 8 [40%] same and 1 [5%] worse.

The preoperative Visual Analogue Pain Score [VAPS] and Oswestry Disability Index [ODI] were set at 100 for the purposes of analysing the results [n=number in brackets]:

Results show an improvement in the overall pain and disability. However, at two years patients still continued with some 65% of symptoms.

Laparoscopic assisted anterior spinal fusion with the BAK device is safe and reliable with advantages that include reduced operating time, blood loss, post-operative analgesia requirements and hospitalisation. However, the clinical outcome does not appear to give superior results to other implants and we question whether it use as a stand-alone device is sufficient and would recommend posterior stabilisation to confer improved mechanical stability.