Background: Anterior scoliosis correctional surgery can result in screw pull out or pedicular fracture. This is more common in stiff curves where the instrumentation extends to the smaller, higher, thoracic levels. The fracture/intra-operative pull out usually occurs during the reduction maneuver. In all of our cases the curve was reduced in the standard cranial to caudal direction using a cantilever maneuver. We describe a salvage technique using circlage wires that can be used for this problem. We present seven cases and the final outcome.

Methods: The technique involves placing a longer screw into the damaged vertebrae so it protrudes 5mm proud. A 1.25mm circlage wire is then cut to length and passed around the tip of the screw. It is then looped in a figure of eight passed under the rod and tightened around the respective pedicle screw head. A case record and x- ray review of seven procedures performed was then carried out. The age of the patients was between 14 and 41 years (mean 20) at surgery. The pre-operative Cobb was between 72 and 43 (mean 58). One curve was flexible with a flexibility index of 70% but the remainder was stiffer (range 34%–40%). There was one thoracolumbar curve with a T11 fracture. All other curves were thoracic and the fracture levels were T5, T7, T7, T6+7, T6+7+8, and T6+7+8 respectively. Four out of seven were braced post operatively for three months. The Cobb angle over the instrumented levels immediately post surgery and at final follow up was measured. The technique was deemed to be successful if no significant loss of correction occurred.

Results: The technique held position in six out of seven of the subjects. The average loss of position in these patients was two degrees (range 0–4). In one subject the curve went from 28 degrees immediately post operatively to 38 degrees over 2 years. The four month post operative x ray showed no loss of position suggesting that this loss of position may not be due to the fracture. This patient remained pleased with his cosmetic result and went from 72 degrees pre operatively to 38 degrees at 2 year follow up.

Conclusion: Care should be taken in patients with stiff proximal curves. The use of larger 8mm screws may decrease pull out and consideration may be given to caudal to cranial reduction in some cases. Circlage wire rescue is a useful salvage procedure for inter-operative fracture or screw pull out during anterior scoliosis correction.

We present a review of 553 patients who underwent surgery for intractable sciatica ascribed to prolapsed lumbar intervertebral disc. One surgeon in one institution undertook or supervised all the operations over a period of 16 years.

The total number of primary discectomies included in the study was 531, of which 42 subsequently required a second operation for recurrent sciatica, giving a revision rate of 7.9%. Factors associated with reoperation were analysed. A contained disc protrusion was almost three times more likely to need revision surgery, compared with extruded or sequestrated discs. Patients with primary protrusions had a significantly greater straight-leg raise and reduced incidence of positive neurological findings compared with those with extruded or sequestrated discs. These patients should therefore be selected out clinically and treated by a more enthusiastic conservative programme, since they are three times more likely to require revision surgery.

Objective: To identify risk factors associated with patients that required revision surgery for sciatica.

Design: A retrospective study of 580 patients who underwent surgery for intractable sciatica attributable to pro-lapsed lumbar intervertebral disc from 1986 to 2000 inclusive.

Subjects: The study included a total of 580 patients. Of these seven patients had an operation at two levels, 25 patients had had a primary operation elsewhere and were therefore excluded; four sets of notes remain missing. The total number of primary operations analysed was therefore 558.

Outcome measures: Parameters such as gender, age, level and side of discectomy were entered into a database for analysis. Diagnostic and clinical parameters were also entered; these included the value of the angle of the straight leg raise recorded and absence or presence of neurological deficit (altered sensation, reduced motor power, and absent or diminished reflexes). Operative findings recorded and entered were the type of disc at operation (i. e. protrusion, extrusion and sequestration) and the presence of free cerebrospinal fluid (CSF), however minor, indicating a dural tear.

Results: The total number of primary discectomies was 558 of which 43 went on to require a second operation, giving a revision rate of 7.71%. Of the primary discectomies, 356 were protrusions, 92 extrusions and 110 sequestration. Of the 43 that went onto revision surgery, 35 were protrusions, two extrusion and six sequestration. A significant association was found with primary disc protrusions, this type of disc prolapse was almost three times more likely to go on to need revision surgery compared to extruded or sequestrated discs. Data analysed on primary protrusions showed these patients had a significantly greater straight leg raise angle and reduced incidence of positive neurological findings and so could be identified clinically.

Conclusions: This lead us to conclude that the group of patients with primary protrusions could be selected out and treated conservatively since they are three times more likely to require revision surgery.