To compare the complication profile of a muscle splitting approach to the anterior cervical spine with previously described approaches.

The authors describe and compare the complications of an approach that exposes the anterior cervical spine by directly splitting the strap muscles in the midline with blunt dissection thereby potentially reducing iatrogenic complications.

A retrospective review of 62 operations to the anterior cervical spine, between 2002 and 2009. Indications: Fusion and arthroplasty procedures for brachalgia, axial neck pain and trauma.

The postoperative complications.

The complication rate was favourable compared to previously described approaches.

The muscle splitting approach to the anterior cervical spine has a low complication rate compared to previously described approaches, and allows the cervical spine to be approached with blunt dissection thereby potentially minimising iatrogenic approach related complications.

Objective: Axially loaded MRI simulates imaging of the lumbar spine in the standing position and is useful in the assessment of spinal stenosis[1]. This study determines the ability of axially loaded spinal MRI to assess Cobb angle in patients with idiopathic scoliosis.

Design: Prospective study. Newly diagnosed patients with idiopathic scoliosis were referred for MRI of the whole spine. Cobb angle measurements were made from erect AP spinal radiographs prior to MRI. Coronal MR images of the thoracic and/or lumbar spine were obtained prior to and following loading of the spine in an MR compatible compression device (Dynawell). Cobb angle measurements were made on unloaded and loaded MRI studies using the same reference points as on radiographs. Radiographic and MRI Cobb angle measurements were compared. Informed consent was obtained from all patients and the study was approved by the local Ethics Committee.

Subjects: Five patients, all females with mean age 14 years (range 12–16 years) were included in the study. Outcome Measures: Six curves were compared on pre-referral erect radiographs, unloaded and loaded MRI studies, 2 in the thoracic region and 4 in the thoracolumbar region.

Results: Curve characteristics and Cobb angle measurement on radiographs vs. axial unloaded and loaded MRI were as follows: Curve 1; T4-T12, 45°, 36° and 41°. Curve 2; T10-L4, 52°, 22° and 30°. Curve 3; T10-L4, 45°, 36° and 38°. Curve 4; T6-T10, 42°, 22° and 22°. Curve 5; T11-L3, 43°, 32° and 43°. Curve 6; T11-L3, 34°, 11° and 31°

Conclusions: Axial loading increases MRI Cobb angle measurements compared to unloaded studies. Initial results suggest that axial loaded MRI using the Dynawell Compression device may allow comparative measurement of Cobb angle to erect radiographs in the thoracolumbar region, but not in the thoracic region. This is likely related to the loading characteristics of the compression device, which is designed to concentrate loading in the lumbar region. Modification to include loading of the thoracic spine may improve results. The technique has the potential to replace radiography and thus reduce radiation burden to young adolescents with some types of idiopathic scoliosis.

Introduction: Somatosensory evoked potentials are monitored during the surgical treatment of spinal disorders to reduce the risk of cord injury. Whilst studies have examined its role in patients undergoing correction of idiopathic and neuromuscular scoliotic curves, its effectiveness in patients undergoing operative treatment for spinal injury is less certain.

Methods and Results: We reviewed the medical records of patients who underwent surgery for spinal trauma. between 1995 and 2000. There were 82 patients with adequate data for analysis who underwent 83 spinal reconstructive procedures. We recorded the age at injury, diagnosis, time of operation, levels instrumented, systolic and diastolic blood pressures and surgical approach. The intraoperative somatosensory evoked potential (SSEP) traces were examined. The SSEP at insertion of electrode was taken as the control level. The highest and lowest intraoperative somatosensory evoked potentials and SSEP at closure were noted and expressed as a percentage of the control value.

Forty patients (48%) had a pre-operative neurological deficit. Neurological deterioration occurred postoperatively in three patients. Eighty-three traces from 82 patients were available for analysis. Fifty-seven patients had a fall in trace amplitude by more than 25% of the control, 25 by more than 50% and eight by more than 75%.

With an SSEP amplitude loss of 60%, both sensitivity and specificity for the prediction of post-operative neurological injury were optimised at 67 and 81% respectively, with one false negative result.

SSEP rise at completion of spinal reconstruction and highest intraoperative SSEP rise was compared with neurological outcome in the 40 patients with abnormal pre-operative neurology. Neurology improved in all patients in this group who had a trace amplitude more than 60% above the control value at end of operation. None had neurological deterioration. There was no correlation between intraoperative SSEP rise and neurological outcome.

Conclusion: Loss of trace amplitude more than 50% is common during spinal reconstructive surgery after trauma, however a 60% threshold for SSEP fall improves specificity by reducing the rate of false positive results. A trace amplitude 60% above the control value at completion of operation is specific but not sensitive for postoperative neurological improvement.

Introduction: Pelvic obliquity is a constant problem in neuromuscular scoliosis. Galveston and Luque L rod techniques are well described and achieve good correction of pelvic obliquity. We describe a sacral and iliac screw construct integrated with double-rod, pedicle screws and hook system, for correction of pelvic obliquity.

Method: 44 patients underwent posterior or combined anterior and posterior fusion to pelvis, for correction of neuromuscular scoliosis and pelvic obliquity. Average age at the time of surgery was 13.8 years. All patients were wheelchair-bound and nine of them were therapeutic walkers. Average follow-up was 44 months (range 24–69 months). Twenty-six patients had combined anterior and posterior surgery. All patients had posterior instrumentation to pelvis and 18 had anterior instrumentation as well. Eighteen patients had posterior instrumented fusion alone. Anterior instrumentation (when used) was Synergy and posterior instrumentation was Synergy or Colorado for all patients.

Result: Average time for surgery was 5 hours and 20 minutes and average blood loss 3600 ml. The average pre-operative Cobb angle was 69° and pelvic obliquity 23°. Post-operative average Cobb angle was 29° and pelvic obliquity 7.5°. At the latest follow-up the average Cobb angle was 36° and pelvic obliquity 10°. There were three deep wound infections. Two of the sacral screws have become prominent and two patients had de-linking of the iliac screw with the rod on one side. None showed significant loss of correction.

Conclusion: The sacraliliac screw construct with double rod segmental instrumentation achieved good correction of pelvic obliquity in patients with neuromuscular scoliosis. Implant related problems were infrequent

Background: The incidence of intra-spinal abnormality in congenital scoliosis is high. McMaster et al found an 18% incidence of myelographic abnormality in a series of 251 patients. Our objective was to report the MRI findings in a large series of patients with congenital scoliosis.

Method: The notes, X-rays and MRI of 126 congenital scoliosis patients were reviewed to note the vertebral abnormality, curve progression, MRI findings and the presence of non-spinal congenital abnormality. These findings were then correlated to detect any association between them.

Result: Forty-six patients (37%) had intra-spinal abnormalities detected on MRI. Sixty-six patients had failure of formation, 10 had failure of segmentation, 34 had mixed vertebral anomaly and 16 had congenital kyphosis or dislocation. MRI abnormality was significantly higher among patients with mixed anomaly (41%), congenital kyphosis (57%) and segmentation anomaly (40%) than those with failure of formation (29%). Presence of MRI abnormality did not correlate with curve progression or the presence of congenital abnormality affecting other organs.

Conclusion: Intra-spinal abnormality in congenital scoliosis occurred in 37% cases. The incidence of such abnormality is higher in patients with congenital kyphosis, failure of segmentation and mixed vertebral anomalies.

Background: Surgical treatments described for congenital spinal deformity are i) convex growth arrest, ii) posterior or combined anterior and posterior fusion and iii) hemivertebrectomy. Posterior instrumentation is used as an adjunct to fusion, whenever possible.

Anterior instrumentation for correction of congenital scoliosis has not been described. A preliminary report of the use of anterior instrumentation following hemi-vertebrectomy for correction of congenital spinal deformity is reported.

Method: 15 patients with congenital scoliosis and 5 patients with congenital kyphosis underwent hemiverte-brectomy and anterior instrumentation with fusion for single-stage correction of deformity . The average age of the patients at the time of surgery was 31 months and at last follow-up 59 months. All patients had pre-operative MRI. Twelve patients had normal and 8 had abnormal MRI. The average operating time was 135 minutes and average blood loss was 462 ml. Implants used were downsize Synergy, Orion Colorado and AO Cervifix.

Average sagittal Cobb angle for the scoliosis patients was 45.5° pre-operatively and 16.8° post-operatively. Average coronal Cobb angle in patients with congenital kyphosis was 61° pre-operatively and 21° postoperatively. At an average follow-up of 17 months, the correction is well maintained in all except one. This patient developed pseudarthrosis at 19 months post-operatively. This was treated with posterior instrumented fusion. There were no cases of neurologic compromise or deep wound infection.

Conclusion: Because of the young age at which hemiver-tebrectomy is performed in congenital scoliosis patients, instrumentation is difficult. Posterior instrumentation has been well described in literature. Our early experience with anterior instrumentation after hemivertebrectomy shows promising results with very good correction of the deformity and no increase in complication rate.

We studied 56 patients with fractures of the tibial shaft in a multicentre prospective randomised trial of three methods of external fixation. Group I was treated with a fixator which was unlocked at 4 to 6 weeks to allow free axial compression (axial dynamisation) with weight-bearing. Group II was treated with a fixator that was similarly unlocked at 4 to 6 weeks but included a small silicone spring which on weight-bearing could be compressed by up to 2 mm. this spring returns to its original length on cessation of weight-bearing thus allowing cycles of motion of up to 2 mm. Group III had a spring fixator like group II, but it was unlocked from the start to allow cyclical micromovement as soon as weight-bearing began. Fracture healing was monitored by the measurement of fracture stiffness. We defined healing as achieving a stiffness of 15 Nm per degree. The mean time was 14.1 weeks in group I, 15.9 weeks in group II, and 19.3 weeks in group III. The difference between groups was statistically significant (p = 0.004). The 95% confidence intervals for the average delay in healing with early cyclical micromovement (group III) as compared with later axial dynamisation (group I) was 1.8 to 8.7 weeks. The healing time in patients whose cyclical micromovement was delayed for 4 to 6 weeks (group II) was between these two extremes, but the differences from either of the other groups could have been due to patient selection. In the patients who completed the full trial, there were pin-track infections in over 60% of those in the cyclical micromovement groups compared with 20% in the axial dynamisation group (p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Screw devices used to treat fractures of the femoral neck are usually positioned under image-intensifier control, using anteroposterior and lateral views. The volume projected by these views is over 27% larger than the femoral head; the tips of screws so placed may be outside the femoral head. This can be avoided by placement within the central two-thirds of the head: we have designed a template which can confirm safe placement.