We assigned 67 patients with central lumbar stenosis alternately to either multiple laminotomy or total laminectomy. The protocol, however, allowed multiple laminotomy to be changed to total laminectomy if it was thought that the former procedure might not give adequate neural decompression. There were therefore three treatment groups: group I consisting of 26 patients submitted to multiple laminotomy; group II, 9 patients scheduled for laminotomy but submitted to laminectomy; and group III, 32 patients scheduled for, and submitted to, laminectomy. The mean follow-up was 3.7 years. Bilateral laminotomy at two or three levels required a longer mean operating time than total laminectomy at an equal number of levels. The mean blood loss at surgery and the clinical results did not differ in the three groups. The mean subjective improvement score for low back pain was higher in group I but there was also a higher incidence of neural complications in this group. No patient in group I had postoperative vertebral instability, whereas this occurred in three patients in groups II and III, who had lumbar scoliosis or degenerative spondylolisthesis preoperatively. Multiple laminotomy is recommended for all patients with developmental stenosis and for those with mild to moderate degenerative stenosis or degenerative spondylolisthesis. Total laminectomy is to be preferred for patients with severe degenerative stenosis or marked degenerative spondylolisthesis

1 . Standard lumbar laminectomy was performed at multiple levels in thirty dogs, and manipulations were carried out in the spinal canal to observe their effects on periradicular adhesion formation. The canal was scarified, packed with Gelfoam, or treated with three varieties of Silastic membranes. The results were serially assessed from three days to twelve weeks by gross observation, nerve conduction studies, histological examination of transverse sections of the spine, myelin study of lumbar roots and micropaque study of the arterial supply to the roots. 2. The results were consistent biologically. The principal source of scar is dorsally in the fibrous tissue elements of the erector spinae muscle mass. This scar, the laminectomy membrane, covers the laminectomy defect and extends into the canal bilaterally to adhere to the dura and nerve roots. 3. Gelfoam does not contribute to scar formation, but instead acts as an effective interposing membrane. Silastic membranes are capable of providing protection against nerve root adhesions without interfering with the anatomical or physiological integrity of the nerves. 4. Certain clinical implications of the study are discussed

We have developed criteria to determine the appropriate indications for lumbar laminectomy, using the standard procedure developed at the RAND corporation and the University of California at Los Angeles (RAND-UCLA). A panel of five surgeons and four physicians individually assessed 1000 hypothetical cases of sciatica, back pain only, symptoms of spinal stenosis, spondylolisthesis, miscellaneous indications or the need for repeat laminectomy. For the first round each member of the panel used a scale ranging from 1 (extremely inappropriate) to 9 (extremely appropriate). After discussion and condensation of the results into three categories laminectomy was considered appropriate in 11% of the 1000 theoretical scenarios, equivocal in 26% and inappropriate in 63%. There was some variation between the six categories of malalignment, but full agreement in 64% of the hypothetical cases. We applied these criteria retrospectively to the records of 196 patients who had had surgical treatment for herniated discs in one Swiss University hospital. We found that 48% of the operations were for appropriate indications, 29% for equivocal reasons and that 23% were inappropriate. The RAND-UCLA method is a feasible, useful and coherent approach to the study of the indications for laminectomy and related procedures, providing a number of important insights. Our conclusions now require validation by carefully designed prospective clinical trials, such as those which are used for new medical techniques

Aims. The optimal procedure for the treatment of ossification of the posterior longitudinal ligament (OPLL) remains controversial. The aim of this study was to compare the outcome of anterior cervical ossified posterior longitudinal ligament en bloc resection (ACOE) with posterior laminectomy and fusion with bone graft and internal fixation (PTLF) for the surgical management of patients with this condition. Methods. Between July 2017 and July 2019, 40 patients with cervical OPLL were equally randomized to undergo surgery with an ACOE or a PTLF. The clinical and radiological results were compared between the two groups. Results. The Japanese Orthopaedic Association (JOA) score and recovery rate in the ACOE group were significantly higher than those in the PTLF group during two years postoperatively, provided that the canal occupying ratio (COR) was > 50%, or the K-line was negative. There was no significant difference in JOA scores and rate of recovery between the two groups in those in whom the COR was < 50%, or the K-line was positive. There was no significant difference in the Cobb angle between C2 and C7, sagittal vertical axis, cervical range of motion (ROM), and complications between the two groups. Conclusion. Compared with PTLF, ACOE is a preferred surgical approach for the surgical management of patients with cervical OPLL in that it offers a better therapeutic outcome when the COR is > 50%, or the K-line is negative, and it also preserves better cervical curvature and sagittal balance. The prognosis of ACOE is similar to that of PTLE when the COR is < 50%, or the K-line is positive. Cite this article: Bone Joint J 2023;105-B(4):412–421

1. One hundred and sixty cases of incomplete or complete paraplegia due to extradural malignant tumour have been reviewed. Between 1959 and 1969 laminectomy for decompression of the cord was performed in 154 of these cases as an urgent measure and the results in 129 cases with full records have been assessed. 2. Immediate laminectomy, a palliative procedure, gave worthwhile improvement in 35 percent of cases of incomplete paraplegia; such patients could walk and had satisfactory control of bladder function at least six months after operation. 3. There were no satisfactory results when the paraplegia was complete. 4. The relief of pain following decompression may be gratifying, even if the patient does not improve sufficiently to fulfil the criteria of a satisfactory result. 5. The results emphasise the importance of early diagnosis, myelography and decompression if a patient with incomplete paralysis is to be offered any chance of relief

1. The usual methods of posterior arthrodesis of the lumbo-sacral joint are not satisfactory in cases in which laminectomy has been performed. 2. Estimation of fusion by mobility radiographs is unreliable and cannot distinguish between fibrous ankylosis and bony fusion. 3. Bone grafts inserted from behind between the vertebral bodies almost invariably fail to become incorporated. 4. Intertransverse arthrodesis has given promising results and is probably the best method available at present

Postoperative radiculopathy is a complication of posterior cervical decompression associated with tethering of the nerve root. We reviewed retrospectively 287 consecutive patients with cervical compression myelopathy who had been treated by multilevel cervical laminectomy and identified 37 (12.9%) with postoperative radiculopathy. There were 27 men and ten women with a mean age of 56 years at the time of operation. The diagnosis was either cervical spondylosis (25 patients) or ossification of the posterior longitudinal ligament (12 patients). Radiculopathy was observed from four hours to six days after surgery. The most frequent pattern of paralysis was involvement of the C5 and C6 roots of the motor-dominant type. The mean time for recovery was 5.4 months (two weeks to three years). The results at follow-up showed that the rate of motor recovery was negatively related to the duration of complete recovery of postoperative radiculopathy (γ = −0.832, p < 0.01) and that patients with spondylotic myelopathy had a significantly better rate of clinical recovery than those with ossification of the posterior longitudinal ligament (t = 2.960, p < 0.01). Postoperative radiculopathy may be prevented by carrying out an anterior decompression in conjunction with spinal fusion, which will achieve stabilisation and directly remove compression of the cord at multiple levels

1. The results of wide laminectomy of the fifth lumbar vertebra and disc excision in 132 patients are reviewed and compared with some published results of the interlaminar operation. 2. There was no significant difference in either the immediate or the long-term results of the two operations suggesting that post-operative morbidity was not related to operative technique. 3. The incidence of post-operative back pain was found to increase with age at operation, duration of pre-operative symptoms and length of follow-up, and supported the impression that backache is predominantly a feature of the underlying degenerative process rather than the incidental operation. 4. The significance of recurrent disc lesions is discussed. Recurrence usually occurred at the previously cleared disc space and was thought to indicate incomplete degeneration of the disc at the time of the original operation. 5. The place of fusion combined with disc excision is discussed. No reliable indications for coincident fusion were found in this series. 6. The value of radiography is discussed. Plain radiographs were essential before operation to exclude other causes of backache and sciatica; otherwise they were of little value. Motion radiographs were no more helpful and myelography was used only when the level of the lesion was in doubt. 7. The risk of an acute cauda equina lesion following manipulation of a prolapsed lumbar disc is noted and the danger of manipulation, unless facilities for emergency surgery are available, is stressed

1. A review of 204 cases of prolapsed intervertebral disc treated by the author by operation ten to twenty-five years before is presented. Injury was an etiological factor in only 14 per cent.

2. The decision to operate should be made after a clearly defined and controlled, but limited, period of closed treatment. The patients should not have to wait for operation. Treatment by closed methods should not be continued in the absence of detectable signs of improvement. Continuation under such circumstances delays recovery from paralysis, prolongs convalescence and delays return to work. Persistence of paraesthesia and numbness are other probable consequences of such delay.

3. A central disc prolapse is an indication for urgent operation if persistent sphincter disturbance or incomplete bladder evacuation is to be avoided.

4. A recurrence rate of sciatica less frequent than that associated with treatment by closed methods is noted in this and other reported series. True recurrence, as opposed to a prolapse at another level, is rare and is most probably due to continuation of the biochemical process of degeneration leading to further sequestration of disc tissue. On the other hand, the altered spinal mechanics, particularly local rigidity resulting from enucleation of a deranged intervertebral disc, may predispose to prolapse at a higher level or may themselves be the cause of symptoms of "recurrence".

5. Operation gives early and lasting relief of sciatic pain, reduces the need for the subsequent use of a corset and assists the patient to an early return to work.

6. Operation does not affect the decision to change work. This is decided by the length of history before operation and the amount of disc degeneration; and the need to change work is the same whether the patient is treated by closed means or by operation.

7. Apart from simple back raising exercises to strengthen the spinal extensor muscles, no physiotherapy need be given because it is not likely to improve the prognosis.

8. Backache is the most frequent disability after operation (17 per cent) and is related to the degree of degenerative change present before and after operation. Injury precipitated the onset of backache in three cases. Operation does not by itself produce backache. The amount of bone removed has no demonstrable effect on the late results of operation, nor on the subsequent development of degenerative changes.

9. Enucleation of the nucleus is not followed by fibrous ankylosis across the intervertebral space.

Aims. The aim of this study was to investigate the clinical and radiographic outcomes of microendoscopic laminotomy in patients with lumbar stenosis and concurrent degenerative spondylolisthesis (DS), and to determine the effect of this procedure on spinal stability. Patients and Methods. A total of 304 consecutive patients with single-level lumbar DS with concomitant stenosis underwent microendoscopic laminotomy without fusion between January 2004 and December 2010. Patients were divided into two groups, those with and without advanced DS based on the degree of spondylolisthesis and dynamic instability. A total of 242 patients met the inclusion criteria. There were 101 men and 141 women. Their mean age was 68.1 years (46 to 85). Outcome was assessed using the Japanese Orthopaedic Association and Roland Morris Disability Questionnaire scores, a visual analogue score for pain and the Short Form Health-36 score. The radiographic outcome was assessed by measuring the slip and the disc height. The clinical and radiographic parameters were evaluated at a mean follow-up of 4.6 years (3 to 7.5). Results. There were no significant differences in the preoperative measurements between the group and no significant differences between the clinical parameters at the final follow-up. The mean percentage slip was 17.1% preoperatively and 17.7% at the final follow-up (p = 0.35). Progressive instability was noted in 13 patients (8.2%) with DS and 6 patients (7.0%) with advanced DS, respectively (p = 0.81). There was radiological evidence of restabilization of the spine in 30 patients (35%) with preoperative instability. The success rate of microendoscopic laminotomy was good/excellent in 166 (69%), fair in 49 (20%) and poor in 27 patients (11%) in both groups. Conclusion. Microendoscopic laminotomy is an effective form of surgical treatment for patients with DS and stenosis. Preservation of the stabilizing structures using this technique prevents postoperative instability. Cite this article: Bone Joint J 2018;100-B:499–506

Aims. Our aim was to perform a systematic review of the literature to assess the incidence of post-operative epidural haematomas and wound infections after one-, or two-level, non-complex, lumbar surgery for degenerative disease in patients with, or without post-operative wound drainage. Patients and Methods. Studies were identified from PubMed and EMBASE, up to and including 27 August 2015, for papers describing one- or two-level lumbar discectomy and/or laminectomy for degenerative disease in adults which reported any form of subcutaneous or subfascial drainage. Results. Eight papers describing 1333 patients were included. Clinically relevant post-operative epidural haematomas occurred in two (0.15%), and wound infections in ten (0.75%) patients. Epidural haematomas occurred in two (0.47%) patients who had wound drainage (n = 423) and in none of those without wound drainage (n = 910). Wound infections occurred in two (0.47%) patients with wound drainage and in eight (0.88%) patients without wound drainage. Conclusion. These data suggest that the routine use of a wound drain in non-complex lumbar surgery does not prevent post-operative epidural haematomas and that the absence of a drain does not lead to a significant change in the incidence of wound infection. Cite this article: Bone Joint J 2016;98-B:984–9

Operative treatment was performed in nine patients with cervical spondylotic myelopathy complicating athetoid cerebral palsy. The first two patients were treated by laminectomy, and the other seven by anterior interbody fusion. The symptoms in both the laminectomy patients improved after operation, but became worse again when cervical instability developed; they then had to have an anterior fusion in addition. In six of the seven patients who had primary anterior fusion a halo-cast (or a halo-vest) was used to keep the cervical spine immobile, and good bony fusion was obtained with satisfactory results. However, in one patient no halo apparatus was used, bony union did not occur and the radiculopathy reappeared. In cervical myelopathy complicating athetoid cerebral palsy laminectomy is contra-indicated; anterior fusion combined with a halo apparatus is, however, satisfactory

Doubt remains as to the safest surgical approach to the prolapsed thoracic intervertebral disc. Laminectomy, lateral rhachotomy and the transthoracic approach all have their protagonists. Twenty-two patients from the National Hospital for Nervous Diseases, Queen Square, and Atkinson Morley's Hospital have been reviewed. Their clinical presentation is discussed and the ancillary aids to diagnosis assessed. The diagnostic value of disc space calcification is stressed, and the use of air myelography as an adjunct to positive contrast myelography is noted. Fifteen patients were subjected to laminectomy, and seven to lateral rhachotomy. Each group contained patients with a wide range of neurological deficit. Six of the patients who underwent laminectomy were improved, two were unchanged, six deteriorated and one died. Of the patients who had lateral rhachotomy, six were improved, one was unchanged and none deteriorated. The conclusion is drawn that lateral rhachotomy is a safer procedure

Initial treatment of traumatic spinal cord injury remains as controversial in 2023 as it was in the early 19th century, when Sir Astley Cooper and Sir Charles Bell debated the merits or otherwise of surgery to relieve cord compression. There has been a lack of high-class evidence for early surgery, despite which expeditious intervention has become the surgical norm. This evidence deficit has been progressively addressed in the last decade and more modern statistical methods have been used to clarify some of the issues, which is demonstrated by the results of the SCI-POEM trial. However, there has never been a properly conducted trial of surgery versus active conservative care. As a result, it is still not known whether early surgery or active physiological management of the unstable injured spinal cord offers the better chance for recovery. Surgeons who care for patients with traumatic spinal cord injuries in the acute setting should be aware of the arguments on all sides of the debate, a summary of which this annotation presents.

Cite this article: Bone Joint J 2023;105-B(4):347–355.

We present a novel method of performing an ‘open-door’ cervical laminoplasty. The complete laminotomy is sited on alternate sides at successive levels, thereby allowing the posterior arch to be elevated to alternate sides. Foraminotomies can be carried out on either side to relieve root compression. The midline structures are preserved. We undertook this procedure in 23 elderly patients with a spondylotic myelopathy. Each was assessed clinically and radiologically before and after their operation. Follow-up was for a minimum of three years (mean 4.5 years; 3 to 7). Using the modified Japanese Orthopaedic Association scoring system, the mean pre-operative score was 8.1 (6 to 10), which improved post-operatively to a mean of 12.7 (11 to 14). The mean percentage improvement was 61% (50% to 85.7%) after three years. The canal/vertebral body ratio improved from a mean of 0.65 (0.33 to 0.73) pre-operatively to 0.94 (0.5 to 1.07) postoperatively. Alternating cervical laminoplasty can be performed safely in elderly patients with minimal morbidity and good results

Percutaneous placement of pedicle screws is a well-established technique, however, no studies have compared percutaneous and open placement of screws in the thoracic spine. The aim of this cadaveric study was to compare the accuracy and safety of these techniques at the thoracic spinal level. A total of 288 screws were inserted in 16 (eight cadavers, 144 screws in percutaneous and eight cadavers, 144 screws in open). Pedicle perforations and fractures were documented subsequent to wide laminectomy followed by skeletalisation of the vertebrae. The perforations were classified as grade 0: no perforation, grade 1: < 2 mm perforation, grade 2: 2 mm to 4 mm perforation and grade 3: > 4 mm perforation. In the percutaneous group, the perforation rate was 11.1% with 15 (10.4%) grade 1 and one (0.7%) grade 2 perforations. In the open group, the perforation rate was 8.3% (12 screws) and all were grade 1. This difference was not significant (p = 0.45). There were 19 (13.2%) pedicle fractures in the percutaneous group and 21 (14.6%) in the open group (p = 0.73). In summary, the safety of percutaneous fluoroscopy-guided pedicle screw placement in the thoracic spine between T4 and T12 is similar to that of the conventional open technique. Cite this article: Bone Joint J 2015;97-B:1555–61

Vertebral haemangiomas are usually asymptomatic and discovered fortuitously during imaging. A small proportion may develop variable degrees of pain and neurological deficit. We prospectively studied six patients who underwent eight surgical procedures on 11 vertebral bodies. There were 11 balloon kyphoplasties, six lumbar and five thoracic. The mean follow-up was 22.3 months (12 to 36). The indications for operation were pain in four patients, severe back pain with Frankel grade C paraplegia from cord compression caused by soft-tissue extension from a thoracic vertebral haemangioma in one patient, and acute bleeding causing Frankel grade B paraplegia from an asymptomatic vascular haemangioma in one patient. In four patients the exhibited aggressive vascular features, and two showed lipomatous, non-aggressive, characteristics. One patient who underwent a unilateral balloon kyphoplasty developed a recurrence of symptoms from the non-treated side of the vertebral body which was managed by a further similar procedure. Balloon kyphoplasty was carried out successfully and safely in all patients; four became asymptomatic and two showed considerable improvement. Neurological recovery occurred in all cases but bleeding was greater than normal. To avoid recurrence, complete obliteration of the lesion with bone cement is indicated. For acute bleeding balloon kyphoplasty should be combined with emergency decompressive laminectomy. For intraspinal extension with serious neurological deficit, a combination of balloon kyphoplasty with intralesional alcohol injection is effective

Aims

We compared decompression alone to decompression with fusion surgery for lumbar spinal stenosis, with or without degenerative spondylolisthesis (DS). The aim was to evaluate if five-year outcomes differed between the groups. The two-year results from the same trial revealed no differences.

Aims

The aims of this study were first, to determine if adding fusion to a decompression of the lumbar spine for spinal stenosis decreases the rate of radiological restenosis and/or proximal adjacent level stenosis two years after surgery, and second, to evaluate the change in vertebral slip two years after surgery with and without fusion.

We reviewed 40 patients treated surgically for lumbar stenosis at an average time of 8.6 years after operation. In 32, total laminectomy had been performed and in eight bilateral laminotomy, both at one or more levels. Of the 16 patients with degenerative spondylolisthesis, ten had had a concomitant spinal fusion. Patients were assigned to one of four groups according to the amount of bone regrowth: group 0 had no regrowth and groups I, II, and III, had mild, moderate or marked regrowth, respectively. Only 12% of the patients showed no bone regrowth; 48% were assigned to group I, 28% to group II and 12% to group III. Imaging studies showed varying degrees of recurrent stenosis in patients with moderate or marked bone regrowth. All patients with degenerative spondylolisthesis showed bone regrowth, which was more severe in those who had not had a fusion. The clinical results were satisfactory in most of the patients with mild or no bone regrowth and significantly less good in those with moderate or marked regrowth. In the group with degenerative spondylolisthesis, the proportion of satisfactory results was significantly higher in patients who had had spinal fusion. The long-term results of surgery for lumbar stenosis depend both upon the amount of bone regrowth and the degree of postoperative vertebral stability

Aims

The aim of this study was to investigate the incidence and characteristics of instrumentation failure (IF) after total en bloc spondylectomy (TES), and to analyze risk factors for IF.

Understanding spinopelvic mechanics is important for the success of total hip arthroplasty (THA). Despite significant advancements in appreciating spinopelvic balance, numerous challenges remain. It is crucial to recognize the individual variability and postoperative changes in spinopelvic parameters and their consequential impact on prosthetic component positioning to mitigate the risk of dislocation and enhance postoperative outcomes. This review describes the integration of advanced diagnostic approaches, enhanced technology, implant considerations, and surgical planning, all tailored to the unique anatomy and biomechanics of each patient. It underscores the importance of accurately predicting postoperative spinopelvic mechanics, selecting suitable imaging techniques, establishing a consistent nomenclature for spinopelvic stiffness, and considering implant-specific strategies. Furthermore, it highlights the potential of artificial intelligence to personalize care.

Cite this article: Bone Joint J 2024;106-B(11):1206–1215.

Aims

Traumatic central cord syndrome (CCS) typically follows a hyperextension injury and results in motor impairment affecting the upper limbs more than the lower, with occasional sensory impairment and urinary retention. Current evidence on mortality and long-term outcomes is limited. The primary aim of this study was to assess the five-year mortality of CCS, and to determine any difference in mortality between management groups or age.

Aims

Repeated lumbar spine surgery has been associated with inferior clinical outcomes. This study aimed to examine and quantify the impact of this association in a national clinical register cohort.

Aims

A recent study used the RAND Corporation at University of California, Los Angeles (RAND/UCLA) method to develop anatomical total shoulder arthroplasty (aTSA) appropriateness criteria. The purpose of our study was to determine how patient-reported outcome measures (PROMs) vary based on appropriateness.

Aims

The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI).

Aims

The outcome following the development of neurological complications after corrective surgery for scoliosis varies from full recovery to a permanent deficit. This study aimed to assess the prognosis and recovery of major neurological deficits in these patients, and to determine the risk factors for non-recovery, at a minimum follow-up of two years.

Aims

To evaluate the perioperative complications associated with total en bloc spondylectomy (TES) in patients with spinal tumours, based on the extent and level of tumour resection.

Aims

Iliosacral sarcoma resections have been shown to have high rates of local recurrence (LR) and poor overall survival. There is also no universal classification for the resection of pelvic sarcomas invading the sacrum. This study proposes a novel classification system and analyzes the survival and risk of recurrence, when using this system.

Aims

This study, using a surgeon-maintained database, aimed to explore the risk factors for surgery-related complications in patients undergoing primary cervical spine surgery for degenerative diseases.

Aims

To describe the clinical, radiological, and functional outcomes in patients with isolated congenital thoracolumbar kyphosis who were treated with three-column osteotomy by posterior-only approach.

We report the technique and early results of the Dwyer-Hartshill method for segmental fixation of the spine. This uses pedicular screws wired to a rectangular frame and is indicated after laminectomy

1. A case of cervical cord compression due to a congenital anomaly of the arch of the axis, treated successfully by decompressive laminectomy twenty-six years after the onset of symptoms, is described. 2. The significance of bony abnormalities of the cervical spine as a treatable cause of spastic tetraparesis is stressed

An 18-year-old man who presented with weakness in his lower limbs, had an upper motor neurone lesion at the D12-L1 level. At laminectomy two stone-like objects were found which proved to be bundles of tiny pieces of wood. They are thought to have entered the cord through an abdominal penetrating injury sustained six years previously

1. Three patients with backache and spinal cord or cauda equina compression due to Paget's disease of the vertebrae are reported; all three were relieved by laminectomy. 2. One case is of particular interest because it is only the second one reported where compression was due to a single affected vertebra

We report the cases of teenage twin girls presenting within months of each other with severe symptoms from lumbosacral disc prolapses, requiring laminectomy in one and chemonucleolysis in the other. CT scans showed similarities in spinal configuration, including the presence of disc bulges at the L4-5 level. This suggests a strong hereditary factor in prolapse of intervertebral discs, but a review of the literature showed little information on that aspect

A retrospective survey has been made of forty children with spinal tumours. Difficulties in establishing the correct diagnosis are mentioned and the value of radiological and cerebrospinal fluid investigations discussed. The major orthopaedic disabilities are spinal deformity or instability, and paraplegia. The main factor in the development of the former is the site of laminectomy: the higher the level the greater is the likelihood of deformity or instability developing. Measures to prevent this distressing complication are discussed. The role of the orthopaedic surgeon in the management of these children is emphasised

The familiar picture of spinal tuberculosis is one of destruction of adjacent vertebral bodies and of the intervening disc. There are, however, other patients without these radiographic changes and with no clinical deformity who present with symptoms and signs of compression of the spinal cord or cauda equina. These patients fall into two different groups: those with tuberculosis of the neural arch; and those with extra-osseous extradural tuberculosis. Both may require laminectomy, but whereas the first has bony involvement and a cold abscess, the second has neither

1. A case of low back pain due to a sacral extradural cyst is reported. Radiographs of the sacrum showed an ovoid expansion of the sacral canal. Myelography and exploratory laminectomy revealed an extradural cyst associated with a defect in the dural root sleeve surrounding the second left sacral roots. Relief of symptoms followed evacuation of the cyst and repair of the defect. 2. The differential diagnosis of the condition, the varieties of extradural cyst, and the features which distinguish them from perineurial cysts are described

1. A review of nineteen cases of malignant spinal tumour treated surgically is presented. 2. Four cases are presented in detail. 3. The results in terms of survival are not assessed, because the effect of operation on survival cannot be estimated in a small series without controls. However, if the patient does survive for a considerable time, the value of operation can be assessed in terms of its contribution to the quality of survival, in relieving pain or improving or protecting neurological function. 4. The limitations of laminectomy are compared with the possible advantages of anterior approaches

1. Nineteen patients with classical rheumatoid arthritis complicated by severe subluxation of the cervical spine are reported. 2. Thirteen patients had atlanto-axial subluxation. This was the only level ofinvolvement in ten. 3. The next most frequent level to be involved was C.4-5. This occurred in five patients. 4. Eleven patients required surgery for symptoms or signs of spinal cord compression or vertebral artery insufficiency. 5. Operations included six posterior fusions, three anterior fusions and two laminectomies. 6. The differential diagnosis, the radiological findings, the indications for surgery and the results of treatment are discussed

A retrospective study of 32 patients with primary tumours of the cauda equina is presented. Most of the patients were initially diagnosed as having prolapsed intervertebral discs and treated accordingly. The correct diagnosis was eventually made, usually after a long delay, and confirmed by myelography. Treatment consisted of laminectomy and excision of the tumour. Only one tumour was frankly malignant; all the remaining patients were relieved of their pain and the majority recovered completely. The exceptions were those patients with long-standing neurological deficits; this highlights the importance of early diagnosis and correct treatment before irreparable damage occurs

The follow-up of these seventy-three cases suggested the following conclusions:. 1. The clinical signs alone are not always sufficient to make the diagnosis of herniated nucleus pulposus with sufficient accuracy. 2. When positive, myelography was reliable as a means of localising the hernia. 3. In doubtful cases in which conservative treatment failed a clearly positive myelography turned the scale for a well-indicated operation. 4. In doubtful cases a clearly negative myelography has often rightly been a contra-indication for laminectomy. 5. No serious complication from the use of water-soluble contrast medium for myelography has been encountered

Of 232 patients with evidence of lumbar spinal stenosis, 13 had symptoms of meralgia paraesthetica. Myelography demonstrated that in all but one of these 13 cases the L3-4 level was involved by stenosis; in 12 matched control patients with spinal stenosis, none had involvement at this level. We found that both the ligamentum flavum and the laminae at L3-4 level were thicker than in a control group. Decompressive laminectomy at the L3-4 level significantly reduced the area of hypo-aesthesia in the thigh, effecting complete cure in seven of the 11 cases. Meralgia paraesthetica is not uncommon in patients with spinal stenosis and is referable to changes at the L3-4 level. It seems that many cases of meralgia may have a spinal origin

Between 1995 and 1999, 12 patients aged 65 years or more (mean 70.2) with lumbar disc herniation, underwent partial laminectomy and nucleotomy. The results were compared with those of 25 younger patients aged between 20 and 40 years (mean 30.1), who underwent the same surgical procedure. The Japanese Orthopedic Association (JOA) score was used to assess the clinical outcome. The minimum follow-up was 12 months. The pre- and post-operative total JOA scores and the rate of improvement of the JOA score were not significantly different between the elderly (11.1, 24.3 points, and 74.1%), and the younger group (11.6, 26.4 points and 84.5%). The results of this study indicate that the outcome of lumbar discectomy in elderly patients is as good as in younger patients

We studied peridural fibrosis in 16 dogs after laminectomies at the L2, L4 and L6 levels. They received either a free fat graft, a biodegradable mechanical barrier (polyethylene oxide (PEO)/polybutylene terephthalate (PBT) copolymer), or no treatment. The animals were killed after 4, 12, 26 and 52 weeks. Histomorphometry showed extensive and consistent peridural fibrosis in control and PEO/PBT groups. Fat grafts produced significantly less fibrous tissue, but the presence of the fat graft in the bony defect prevented closure. Degradation of the PEO/PBT barrier resulted in the formation of more fibrous tissue. We conclude that up to one year a free fat graft is effective in reducing the amount of peridural scarring

We examined soft tissue biopsies from 26 patients with symptomatic nerve root fibrosis and arachnoiditis after a previous laminectomy. Dense fibrous connective tissue was found about the nerve roots and in 14 cases (55%) fibrillar foreign material was seen within it. This material had the histochemical characteristics of cotton fibres from swabs and neurosurgical patties. In two other cases nerve root fibrosis was associated with residual radiopaque lipid thought to derive from earlier myelography. Our findings suggest that risks may be associated with the introduction of foreign material into the vertebral canal, and that microscopic fragments of surgical swabs and patties may have a role in the pathogenesis of postoperative periradicular fibrosis