Boys affected by Duchenne Muscular Dystrophy (DMD) often develop significant scoliosis in the second decade of life and require scoliosis surgery. Our aim was to establish whether cardiac MRI (CMR) improves the preoperative risk assessment in DMD patients and evaluate the current risk of surgery.

Case records were retrospectively reviewed for 62 consecutive DMD boys who underwent pre-surgical evaluation at a single tertiary neuromuscular centre between 2008–2013.

62 DMD patients aged 7–18 years underwent pre-operative assessment for a total of 70 procedures (45 spinal, 19 foot, 6 gastrostomy). Echocardiography data were available for 68 procedures. Echo revealed a median left ventricular (LV) shortening fraction (SF) of 29% (range: 7–44). 34% of boys (23/68) had abnormal SF <25%, 48% (31/65) showed dyskinesia and 22% (14/64) had LV dilatation. CMR was routinely performed on 35 patients. Of those who underwent CMR, median left ventricular ejection fraction (LVEF) was 52% (range: 27–67%), 71% of boys (25/35) had dyskinesia. Echocardiography shortening fraction (SF) correlated significantly with CMR LVEF (r_s = 0.67; p<0.001). Increasing severity of dyskinesia on CMR correlated with reduced CMR LVEF (r_s = −0.64; p<0.001) and reduced echo SF (r_s = −0.47; p = 0.004). Although functional echocardiography and CMR data tended to correlate in 35 DMD boys who underwent both imaging modalities nine (26%) had discrepant results. Seven (20%) had evidence of dysfunction on CMR (LVEF < 55%) not detected on echocardiography (SF ≥ 27%); in two cases echocardiogram measured worse function than CMR.

Based on multi-disciplinary risk assessment, surgery was considered too high risk in 23 out of 67 (34%) cases. In 21 cases (91%) this was due to underlying cardiomyopathy. The highest risk among older boys assessed for spinal surgery; 21 out of 43 (49%). Of 19 boys undergoing spinal surgery, six (32%) experienced complications: two wound infections; three patients required readmission to intensive care; one patient died in the post-operative period with acute heart failure.

Aims:

Identifying and scoring risk factors that predict early wound dehiscence and progression to metalwork infection. Results of wound healing, eradication of infection and union of with the use of vacuum dressing. Compare results of serial washouts against early vacuum dressing in this group of children with significant medical co-morbidities.

Aim:

Vitamin D deficiency is a common problem in the UK. It is more prevalent in patients with orthopaedic conditions. Previous studies in the literature have shown that vitamin D deficiency is associated with low patient-related outcome scores. To date, no studies have been performed in spinal patients. The aim of this study was to investigate whether there is a relationship between vitamin D status and pre-operative outcome scores in patients with AIS.

PURPOSE

This study aims to identify the incidence and factors influencing readmissions following scoliosis surgery over a period of 19 years.

Purpose

This study aims to identify factors that influence the Cobb angle at presentation to a tertiary referral scoliosis centre, and the outcome of the referrals.

Summary: Radiographic and clinical outcomes of anterior thoraco-lumbar and posterior instrumented spinal fusion in patients with double major (AIS) curves are evaluated in this retrospective study. The average thoracic curve was 68 degrees before surgery and 29.2 degrees at follow-up (mean correction 58.3%). The average preoperative lumbar curve was 73 degrees, decreasing to 18 degrees postoperatively (mean correction 77.5%). Instrumented anterior lumbar fusion followed by posterior instrumented fusion is a successful technique with low morbidity in AIS with double curve pattern.

Introduction: Options exist for the surgical treatment of double major AIS curves. With the introduction of multi-level pedicle screw fixation in the thoracic and lumbar spines the role of anterior surgery is being questioned. This series demonstrates the results obtained by anterior thoraco-lumbar and posterior instrumented spinal fusion.

Methods: 28 patients with double major curves who underwent anterior spinal release and instrumented fusion, with staged posterior instrumented spinal fusion between 1999 and 2005 were included for analysis. The minimum follow-up was 2 years after surgery (mean, 5 years; range, 2–8 years). The mean age of patients was 17,3 years (range, 13–21 years). Multiple radiographic parameters were assessed.

Results: Successful selective thoraco-lumbar instrumented fusion and posterior instrumented fusion was performed in 28 consecutive patients with adolescent idiopathic scoliosis. The average thoracic curve was 68 degrees before surgery and 29,2 degrees at final follow-up (mean correction 58,3%). The average pre-operative lumbar curve was 73 degrees, decreasing to 18 degrees postoperatively (mean correction 77,5%), with good coronal and sagittal balance achieved. Tilt of the lower instrumented vertebra (LIV) improved from 28.2 degrees to 4.6 degrees on last follow-up. Disc angulation below the LIV averaged 6.1 degrees preoperatively and 3.6 degrees on last follow-up. Translation of the LIV from the center sacral vertical line averaged 34.5 mm preoperatively and 13.6 mm on last follow-up.

Discussion: Instrumented anterior lumbar fusion followed by posterior instrumented fusion is a successful technique in adolescent idiopathic scoliosis with double curve pattern. These results show that this technique is able to restore normal coronal alignment of the distal unfused lumbar segment and saves fusion levels compared to posterior instrumentation only. Despite the extensive surgery, there is a very low morbidity in this population, with no evidence of pseudarthrosis.

Significance: This represents a large unique series of patients treated for double major curve pattern in adolescent idiopathic scoliosis with low morbidity and excellent balanced corrections in both coronal and sagital planes.

Study Design: Retrospective study with clinical and radiological evaluation of 15 patients with congenital kyphosis or kyphoscoliosis who underwent anterior instrumented spinal fusion for posterolateral or posterior hemivertebae (HV).

Objective: To evaluate the safety and efficacy of early surgical anterior instrumented fusion with partial preservation of the HV in the treatment of progressive congenital kyphosis in children below the age of 3. We discuss the management of patients presenting with neurological compromise.

Summary of background data: A variety of treatments have been described in the literature for the treatment of congenital kyphosis due to HV. We report the results of our technique.

Materials and Methods: Between 1997 and 2005 we have treated 15 consecutive patients with progressive congenital kyphosis with anterior instrumented fusion and strut grafting. 13 patients had a single posterolateral HV and 2 patients a single posterior HV. Of the 15 patients in the study, 5 were girls and 10 boys. Mean age at surgery was 22 months (range 8–33). Mean follow-up period was 6.8 years. 13 HV were located in the thoracolumbar junction (T10-L2) and 2 in the thoracic spine.

Results: The average operating time was procedure was 150 minutes (range, 130 to 210 minutes). The average blood loss 180 mL (range, 100 to 330 mL), equivalent to a mean external blood volume loss of 15% (range, 11 to 24%).

Preoperative segmental Cobb angle averaging 34 º at last follow up. Compensatory coronal cranial and caudal curves corrected by 50%. The angle of segmental kyphosis averaged 39º (range, 20º to 80º) before surgery and 21 º (range, 11º to 40º) at last follow up. This represents a 43% of improvement of the segmental kyphosis, and a 64% of improvement of the segmental scoliosis at last followup.

One case with initial kyphosis of 80 º continued to progress and required revision anterior and posterior surgery. There were no neurologic complications.

Key points:

In progressive congenital kyphoisis, early diagnosis and aggressive surgical treatment are mandatory for a successful result.

Study Design: Retrospective study with clinical and radiological evaluation of 29 patients with congenital scoliosis who underwent 31 short segment anterior instrumented fusions of lateral hemivertebrae.

Objective: To evaluate the safety and efficacy of early surgical anterior instrumented fusion with partial preservation of the HV in the treatment of progressive congenital scoliosis in children below the age of 6.

Summary of background data: A variety of treatments have been described in the literature for the treatment of HV. We report the results of a novel technique.

Materials and Methods: Between 1996 and 2005, 29 consecutive patients with 31 lateral HV and progressive scoliosis underwent short segment anterior instrumentation and fusion with preservation of the HV. Mean age at surgery was 2.9 years. Mean follow-up period was 6.3 years.

Results: Preoperative segmental Cobb angle averaging 39°, was corrected to 150 after surgery, being 15º at the last follow up (60% of improvement). Compensatory cranial and caudal curves corrected by approximately 50% and did not change significantly on follow up. The angle of segmental kyphosis averaged 13º before surgery, 12º after surgery, and 12° at follow up. There was 2 wound infection requiring surgical debridment, 1 intraoperative fracture of the vertebral body and 1 case lost correction due to implant failure. All went on to stable bony union. There were no neurologic complications.

Conclusions: Early diagnosis and early and aggressive surgical treatment are mandatory for a successful treatment of congenital scoliosis and to prevent the development of secondary compensatory deformities. Anterior instrumentation is a safe and effective technique capable of transmitting a high amount of convex compression allowing short segment fusion which is of great importance in the growing spine

The objective of this study was to assess the clinical outcome and efficacy of the X-Stop™ interspinous implant.

67 patients (36 male, 31 female) with mean age of 62.4 years (range 50–94 years) and radiologically proven lumbar stenosis, underwent X-Stop™ implantation during the period of June 2004 to June 2007. Patients were assessed pre-operatively and post-operatively at 3, 6 and 12 months using the Back and Sciatica Questionnaire, the Oswestry Disability and the SF12 questionnaire. Patient’s satisfaction was assessed in each visit. Minimum follow up 2 years in 45 patients and 1 year in 22 patients.

70% had significant improvement in the walking distance following the operation.

With the Back and Sciatica Questionnaire the average preoperative VAS of back and leg pain was 7.1 and 6.7 and improved to 2.5 and 2.6 postoperatively.

86% patient had improvement in their ODI score by 14% and more with average pre and postoperative score 44% (range18%–84%) and 15.8% (range 0%–61%) respectively.

With the SF12 questionnaire 68% patients had significant improvement in physical score and 77% in the mental score. Complications included five superficial wound infections and one wound haematoma. One patient required revision surgery.

This new surgical technique for the treatment of lumbar spinal stenosis, is simple and effective with minimum complications.

Atlanto-axial rotatory fixation is a rare abnormality of the atlanto-axial joint characterised by a fixed rotated atlanto-axial joint. Duration of symptoms is the best predictor of those cases that ultimately require surgical fixation. We report 6 cases of atlanto-axial rotatory fixation that were treated at the Royal National Orthopaedic Hospital between 1998 and 2005. Diagnosis was confirmed by CT scan in all cases. The mean duration of symptoms was 8 weeks. 4 cases were reduced with halo traction, for between 7–28 days (mean 15 days), and 2 cases were reduced under anaesthesia. This was followed by application of a halo jacket in all 6 cases for between 6–12 weeks (mean 7.2 weeks). There was no significant recurrence with a mean duration of follow up 24 months. This rare series demonstrates late presenters of AARF responding favourably to non surgical intervention.

Background: To assess the use of subcutaneous rodding with sequential lengthening procedures to control progressive early onset curves not responding to conservative treatment modalities.

Methods: A retrospective study reviewing the notes and plain radiographs of all children with early onset scoliosis treated by growth rod insertion over a seven year period (two paediatric spinal surgeons using similar techniques at two major centres). Subjects were children with early onset scoliosis unresponsive to conservative management. Outcome measures – curves at time of instrumentation, curve progression, number of lengthenings, curve magnitude and age at time of definitive fusion, spinal growth achieved and complications encountered.

Results: Majority of children treated uneventfully with satisfactory control of curvature until age at which definitive fusion acceptable. However our results do suggest a number of cases and circumstances where simple growth rod instrumentation is not sufficient and augmentation with anterior apical fusion is required (will discuss these on an individual basis).

Conclusion: The management of early onset progressive scoliosis by means of growth rod instrumentation and sequential lengthenings is safe and effective.

Study Design: A retrospective case-note study.

Objective: To evaluate causes of delayed admission for patients with spinal injuries.

Subjects: 432 patients admitted between March 1998 and March 2003.

Outcome Measures: Patients were analysed with respect to Injury Severity Score (ISS); date of injury, referral and admission independently and length of hospitalisation. The delays between injury and referral (> 3 days) and between referral and admission (> 7days) were correlated to the length of hospitalisation.

Results: There were 322 males (average age, 38.6 years) and 110 females (average age, 41.8 years), with 108 complete injuries, 115 incomplete and 209 intact. The average time between injury and referral was 5.5 days (range 0–94), and between referral and admission was 10.7 days (range 0–130). 161 patients (37%) experienced a delay between injury and referral, of whom 59 (37%) were subsequently also delayed to admission. The principal reason for delay was the treatment of concurrent injuries. Even patients with complete injuries (15/43) experienced delayed referral. 112 patients (26%) experienced a delay between referral and admission. Principal reasons included the provision of beds and stabilisation of concurrent injuries. We found the delay between referral and admission (p< 0.001), the ISS (p< 0.001) and increasing neurological severity of injury (p< 0.001) to be highly significant factors predisposing to longer hospitalisation.

Conclusions: Delayed admission for patients with spinal injuries is common. Provision of beds being the most common preventable reason for delay following referral. Early liason with a designated spinal injuries unit, especially for patients with cord injury remains vitally important.

Objective: To compare the surgical outcome of patients with right thoracic adolescent idiopathic scoliosis undergoing: 1). Single-stage anterior spinal release and posterior instrumented fusion with costoplasty, 2). Staged anterior spinal release and posterior instrumented fusion with costoplasty.

Study Design-Material: A retrospective study was performed including 20 consecutive patients for each surgical group.

Summary of Background Data: Scoliosis surgery in our institution has evolved over the past decade with respect to the interval between the anterior and posterior procedure. It was typical in the 1980’s/early 1990’s for the patients who required combined anterior-posterior spinal fusion to have 2 weeks between stages. This interval has now been reduced to one week by all our scoliosis surgeons. The authors recently endeavor to perform single-stage anterior-posterior procedures with costoplasty for all right thoracic curves in patients with adolescent idiopathic scoliosis.

Methods: The medical records and radiographs of the 40 patients were reviewed.

Results: The patients in both groups have been assessed for: 1). Correction of spinal deformity achieved with the operation, 2). Incidence of perioperative complications, 3). In-patient stay, 4). Postoperative course. The results were comparative between the 2 groups. Considerable curve correction was obtained with the combined anteroposterior spinal surgery and maintained at follow-up in both groups. No difference in the incidence of complications was recorded between the same-day and the staged groups. Less hospitalization time and time spent in the intensive care unit were required for the patients who underwent same-stage sequentially performed anterior-posterior spinal procedures.

Conclusions: This study showed that single-stage anterior-posterior surgery for right thoracic adolescent idiopathic scoliotic curvatures is a safe and efficacious procedure with no documented adverse effects for the patients. We believe that when a combined anteroposterior spinal approach is necessitated, the one-stage surgery could be considered the procedure of choice for the management of this type of scoliotic deformity.

Objective-Study Design: Recognizing the value of intraoperative SEP monitoring in scoliosis and other spinal surgery, we applied prospectively continuous SEP recording during reconstructive procedures in 82 patients who sustained 20 cervical, 8 thoracic, 6 thoraco-lumbar, and 48 lumbar vertebral fractures or fractures-dislocations to investigate its efficacy in spinal trauma.

Material: Seventy-one patients underwent single anterior or posterior operations, and 11 combined anterior-posterior procedures. Forty patients had incomplete injuries, and 42 had no preoperative neurological deficit. SEP trace amplitude at insertion of electrode was considered as the baseline value, and was compared to the lowest intraoperative signal amplitude and the amplitude at completion of operation.

Results: Fifty-nine patients had a depression in wave amplitude of more than 25% during surgery; in 25 patients the trace fell by more than 50%, and in 7 cases a more than 75% diminution was recorded. A loss of 50% in SEP signal amplitude showed 67% sensitivity, and 71% specificity in predicting neurologic outcome. Patients with a fall in SEP amplitude of more than 50% that did not recover at completion of the surgical procedure demonstrated an increased risk of neurological compromise (p< .01). Increasing trace deterioration threshold from 50 to 60% improved specificity to 81% without compromising sensitivity. There was also 100% correlation between the side of the amplitude drop and the side of neurological loss in the trunk or limb (p< .001). A total number of 22 patients had improved SEP recordings before skin closure; 19 of these patients demonstrated an improved neurologic function after the operative procedure. In these 19 patients a positive statistical association could be documented between the signal changes and the neurological outcome (p< .05). Nevertheless, 2 of the patients with up to 20% improvement in the trace amplitude compared to the original control measurement presented deterioration in their neurological picture in the postoperative period. In 17 patients the SEP waveform amplitude was unchanged at conclusion of the operation; in those cases the neurological functional level post-surgery was equally unaltered. No significant difference was obtained when comparing the systolic blood pressures or the core temperatures at skin closure between the different outcome groups (p> .05). A loss of more than 50% in SEP amplitude occurred with significantly increased incidence during the anterior compared to the posterior spinal procedures (p< .001). More than 20% recovery in signal amplitude at conclusion of the procedure in patients with incomplete injuries was correlated with favorable neurological function.

Conclusions: Persistent intraoperative decrement in SEP amplitude and poor restitution at completion of surgery increase the risk for postoperative neurologic compromise. In this series, continuous intraoperative SEP monitoring appeared to be adequately reproducible, sufficiently reliable, and therefore a practical tool in monitoring operative procedures for spinal trauma. Even though compared to deformity surgery the method is less sensitive and specific, it may help reduce the incidence of devastating neurologic injury during the operation on an already compromised neural cord, and can provide good prediction in terms of postoperative neurological outcome. Thus, it could be considered a useful surgical adjunct in the management of patients with spinal trauma.

Lateral oblique radiographs are considered important for the identification of spondylolytic lesions, but these projections will give a clear view only when the radiological beam is in the plane of the defect. We studied the variation in orientation of spondylolytic lesions on CT scans of 34 patients with 69 defects.

There was a wide variation of angle: only 32% of defects were orientated within 15° of the 45° lateral oblique plane. Lateral oblique radiographs should not be considered as the definitive investigation for spondylolysis.

We suggest that CT scans with reverse gantry angle are now more appropriate than oblique radiography for the assessment of spondylolysis. Variation in the angle of the defect may also need consideration when direct repair is being planned.