This is a prospective review of the results of our first 20 Prodisk disc replacements. The prosthesis is designed to maintain lumbar motion and, in theory, to avoid adjacent disc overload.

Nine men and 11 women scheduled for fusion were given the option of arthroplasty. The advantages and disadvantages were explained, as well as the ‘experimental’ nature of the product. Six (30%) of the 20 were Workmen’s Compensation patients. Permission to use patient data was obtained. The mean follow-up was 18 months. All patients completed a back pain questionnaire at initial and last follow-up. Preoperative and postoperative visual analogue scores (VAS) were recorded. The length of time to return to work was documented. All patients presented with severe low back pain and 12 had radiculopathy. All had positive discograms.

The senior author performed the operations after appropriate training, and a vascular surgeon assisted with the exposure. All cases were single level replacements, one at L3/L4, six at L4/L5 and 13 at L5/S1.

The mean preoperative VAS score was 8.6. Postoperatively it was 2.6. Mean anaesthesia time was 100 minutes (55 to 120). In patients other than pensioners, the time to return to work averaged 8 weeks. A special forces policeman and a military helicopter pilot both returned to their pre-injury levels of activity and another patient returned to first league basketball. No serious intraoperative complications occurred. One patient developed DVT in spite of prophylactic Enoxiparine. One ‘upper plate’ dislodged slightly at 20 months. The reason is unclear but the patient remains asymptomatic.

In selected patients, a Prodisk disc replacement is an excellent alternative to fusion, but it is imperative that the guidelines for indications are carefully followed.

The Dynesys fixation device has fewer side effects and complications than conventional fusion techniques, but indications for its use are still unclear. This prospective study of 50 patients treated since October 2000 aimed to determine its efficacy and to establish contra-indications.

Patients considered for lumbar spinal fusions were evaluated to assess whether Dynesys fixation could be used instead of conventional fusion techniques. All patients completed an Oswestry questionnaire preoperatively and again three and six months postoperatively.

Postoperatively all patients were mobilised on day one or two, using only a soft back brace. No limitations were placed on sitting or driving.

All Oswestry and visual pain analogue scores improved dramatically in the short term. Complications included loosening of screws that made further surgery necessary. Three patients required conversion to fusion and one developed disc reherniation.

In the right patient, this method is very effective. All the older patients were clearly better off with this technique, which permits early mobilisation and return to work. The swiftness with which the procedure can be carried out means less exposure, less bleeding and ultimately less fibrosis. Absolute contra-indications are spinal instability (including spondylolisthesis), deformity (including severe degenerative scoliosis), long fixations and revision discectomy. Relative contra-indications include uncomplicated mini-discectomy where no fixation is required and use in very active younger patients.

Many devices have been developed to enhance fusion and alignment of the spine in anterior spinal fusions. The Ulrich ‘Ivory’ interbody cage was introduced in 2000, and this report examines the results of the first 50 patients in whom it was used.

The mean age of the 21 men and 29 women was 50.8 (24 to 74). A total of 82 cages were inserted. In 39 patients the indications for surgery were failed posterior fusions. One patient, who had undergone three previous surgical procedures, had post-laminectomy syndrome. Primary anteroposterior fusion for spondylolisthesis was performed in six patients. The remaining four had surgery for other reasons, including sagittal malalignment and failed Dynesys fixation.

Evaluated radiologically, the fusion mass was good. Complications included one vascular injury, which required repair of the iliac artery. One patient developed pancreatitis and deep vein thrombosis. The posterior surface of S1 fractured in one patient. From six weeks to one year postoperatively, we saw five broken cages, three associated with grade II spondylolisthesis and two that had broken after trauma. Since then, the lateral supports of the cages have been strengthened.

The cage is easy to insert, either laterally or anteriorly. The large contact surface makes for good bony ingrowth and no stress shielding. It is a useful alternative to other cages on the market, but should not be used as a ‘stand alone’ device.

The problems arising at the levels above or below a previous successful fusion are well known. The aim of this study was to determine the incidence of junctional disk degeneration and/or stenosis and to attempt to establish preventative measures.

Between July 1993 and December 2000, a single surgeon performed lumbosacral fusions on 938 patients. The primary fusion was subsequently extended in 26 men and 16 women (2.8%). The mean age of patients at the time of the second fusion was 52 years. The mean time from the primary to a second procedure was three years. Initial data showed that seven patients had mild to moderate degeneration of the disc and/or facet joints above the level of intended fusion. No other risk factors were identified.

At 2.8%, it would appear that extension of a fusion is necessary less often than anticipated. The need for extension may have been prevented in seven patients had the primary fusion been extended.

A report published in 1999 showed that whether stainless steel or titanium screws were used in spinal surgery made little difference to outcome. However, the smaller number of titanium group patients, who had a shorter follow-up period, skewed statistical analysis in the study. The present study re-evaluates the incidence of complications, especially the pseudarthrosis rate, in a series of patients who underwent lumbosacral fusion with a segmental spinal correction system fixation device.

Of over 1 100 patients who underwent surgery between July 1993 and December 2000, 846 could be followed up adequately. Stainless steel devices were used in 410 and titanium implants in 436. There were roughly equal numbers of male and female patients, and occupation and smoking profiles were similar.

The incidence of pseudarthrosis was equal and the incidence of screw breakage was less than 1% in both groups.

There is little in the recent literature about the place of low molecular weight heparin (LMWH) in routine lumbosacral surgery.

This study aimed to determine firstly the risk of deep vein thrombosis (DVT) if Clexane was not given preoperatively, and secondly the complications associated with the use of the drug.

In a prospective study undertaken from January 2001 to April 2001, 64 patients scheduled for routine lumbosacral surgery were entered. We excluded patients with a high risk of DVT. The mean age of patients was 51 years (16 to 75). Patients were randomly selected to receive Endoxaparin (Clexane) preoperatively the night before (38 patients in group 1) or Clexane postoperatively (26 patients in group

2). All patients were evaluated by Doppler sonography pre-operatively, four days postoperatively and at six weeks. Blood loss was monitored intra-operatively and postoperatively. Clexane was administered only for eight days. Posterior lumbosacral spinal procedures only were done on 44 patients, while seven had combined anterior-posterior surgery and 13 anterior procedures only.

Mean intra-operative and postoperative blood losses in group 1 were twice those in group 2, and patients in group 1 tended to bleed for longer. Two cases of partial thrombosis were seen, both group 1. In group 1 intraspinal haematoma formation was seen in four patients, two of whom required additional surgery.

LMWH should not be given preoperatively for routine spinal cases. In fact, it is contra-indicated.

In 2000 the Ulrich ALIF cage for lumbar surgery was introduced. We evaluated the effectiveness and safety of this new implant device by determining fusion rate, cost and complications.

Twenty patients undergoing anterior spinal surgery for failed posterior fusions were offered the option of receiving the implant device and entered into this prospective study. In all patients, the approach was either anterior retroperitoneal or left lateral retroperitoneal. The procedures were done under C-arm control. The mean operating time was 80 minutes. Blood loss was less than 400 ml. Mobilised the day after surgery, all patients used a soft lumbosacral brace for at least six weeks. Follow-up radiographs were taken on the third postoperative day and at six and 12 weeks.

The large bone graft surface of the cage allows excellent bone grafting and radiological visualisation. We encountered no complications related to the cage. One case of anterior subluxation of 1 cm occurred when a patient stumbled on the third day after surgery.