Multiple thoracic disc herniations are rare and there are few reports in the literature. Between December 1998 and July 2002, we operated on 12 patients with multiple thoracic disc herniations. All underwent an anterior decompression and fusion through a transthoracic approach. The clinical outcomes were assessed using the Frankel neurological classification and the Japanese Orthopaedic Association (JOA) score. Under the Frankel classification, two patients improved by two grades (C to E), one patient improved by one grade (C to D), while nine patients who had been classified as grade D did not change. The JOA scores improved significantly after surgery with a mean recovery rate of 44.8% ± 24.5%. Overall, clinical outcomes were excellent in two patients, good in two, fair in six and unchanged in two. Our results indicate that anterior decompression and fusion for multiple thoracic disc herniations through a transthoracic approach can provide satisfactory results

Injury to the spinal cord and kyphosis are the two most feared complications of tuberculosis of the spine. Since tuberculosis affects principally the vertebral bodies, anterior decompression is usually recommended. Concomitant posterior instrumentation is indicated to neutralise gross instability from panvertebral disease, to protect the anterior bone graft, to prevent graft-related complications after anterior decompression in long-segment disease and to correct a kyphosis. Two-stage surgery is usually performed in these cases. We present 38 consecutive patients with tuberculosis of the spine for whom anterior decompression, posterior instrumentation, with or without correction of the kyphus, and anterior and posterior fusion was performed in a single stage through an anterolateral extrapleural approach. Their mean age was 20.4 years (2.0 to 57.0). The indications for surgery were panvertebral disease, neurological deficit and severe kyphosis. The patients were operated on in the left lateral position using a ‘T’-shaped incision sited at the apex of kyphosis or lesion. Three ribs were removed in 34 patients and two in four and anterior decompression of the spinal cord was carried out. The posterior vertebral column was shortened to correct the kyphus, if necessary, and was stabilised by a Hartshill rectangle and sublaminar wires. Anterior and posterior bone grafting was performed. The mean number of vertebral bodies affected was 3.24 (2.0 to 9.0). The mean pre-operative kyphosis in patients operated on for correction of the kyphus was 49.08° (30° to 72°) and there was a mean correction of 25° (6° to 42°). All except one patient with a neural deficit recovered complete motor and sensory function. The mean intra-operative blood loss was 1175 ml (800 to 2600), and the mean duration of surgery 3.5 hours (2.7 to 5.0). Wound healing was uneventful in 33 of 38 patients. The mean follow-up was 33 months (11 to 74). None of the patients required intensive care. The extrapleural anterolateral approach provides simultaneous exposure of the anterior and posterior aspects of the spine, thereby allowing decompression of the spinal cord, posterior stabilisation and anterior and posterior bone grafting. This approach has much less morbidity than the two-stage approaches which have been previously described

A total of 39 HIV-infected adults with spinal tuberculosis underwent anterior spinal decompression for neurological deficit. Fresh-frozen allografts were used in 38 patients. Antituberculous drugs were prescribed for 18 months, but antiretroviral therapy was not used. Six patients died within two years of surgery. Neurological recovery and allograft incorporation were observed at follow-up at a mean of 38 months, although the CD4/CD8 ratios were reversed in all patients. Adequate preoperative nutritional support and compliance with antituberculous treatment are essential in ensuring a satisfactory outcome

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.

Aims. Cervical spondylosis is often accompanied by dizziness. It has recently been shown that the ingrowth of Ruffini corpuscles into diseased cervical discs may be related to cervicogenic dizziness. In order to evaluate whether cervicogenic dizziness stems from the diseased cervical disc, we performed a prospective cohort study to assess the effectiveness of anterior cervical discectomy and fusion on the relief of dizziness. Patients and Methods. Of 145 patients with cervical spondylosis and dizziness, 116 underwent anterior cervical decompression and fusion and 29 underwent conservative treatment. All were followed up for one year. The primary outcomes were measures of the intensity and frequency of dizziness. Secondary outcomes were changes in the modified Japanese Orthopaedic Association (mJOA) score and a visual analogue scale score for neck pain. Results. There were significantly lower scores for the intensity and frequency of dizziness in the surgical group compared with the conservative group at different time points during the one-year follow-up period (p = 0.001). There was a significant improvement in mJOA scores in the surgical group. Conclusion. This study indicates that anterior cervical surgery can relieve dizziness in patients with cervical spondylosis and that dizziness is an accompanying manifestation of cervical spondylosis. Cite this article: Bone Joint J 2018;100-B:81–7

Aims. The purpose of this retrospective study was to investigate the clinical relevance of increased facet joint distraction as a result of anterior cervical decompression and fusion (ACDF) for trauma. Patients and Methods. A total of 155 patients (130 men, 25 women. Mean age 42.7 years; 16 to 87) who had undergone ACDF between 1 January 2001 and 1 January 2016 were included in the study. Outcome measures included the Neck Disability Index (NDI) and visual analogue scale (VAS) for pain. Lateral cervical spine radiographs taken in the immediate postoperative period were reviewed to compare the interfacet distance of the operated segment with those of the facet joints above and below. Results. There was a statistically significant relationship between greater facet distraction and increased NDI and VAS pain scores. This was further confirmed by Spearman correlation, which showed evidence of a moderate correlation between both NDI score and facet joint distraction (Spearman correlation coefficient 0.34; p < 0.001) and VAS score and facet distraction (Spearman correlation coefficient 0.52; p < 0.001). Furthermore, there was a discernible transition point between outcome scores. Significantly worse outcomes, in terms of both NDI scores (17.8 vs 8.2; p < 0.001) and VAS scores (4.5 vs 1.3; p < 0.001), were seen with facet distraction of 3 mm or more. Patients who went on to have a posterior fusion also had increased NDI and VAS scores, independent of facet distraction. Conclusion. After undergoing ACDF for the treatment of cervical spine injury, patients with facet joint distraction of 3 mm or more have worse NDI and VAS pain scores. Cite this article: Bone Joint J 2018;100-B:1201–7

Fresh-frozen allografts from the humerus were used to help to stabilise the spine after anterior decompression for tuberculosis in 47 children with a mean age of 4.2 years (2 to 9). The average angle of the gibbus, before operation, was 53°; at follow-up, two years later, it was 15°. Rejection of the graft or deep sepsis was not seen. Cross trabeculation between the allograft and the vertebral body was observed at six months, with remodelling occurring at approximately 30 months

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

Aims

Spinal tuberculosis (TB) remains an important concern. Although spinal TB often has sequelae such as myelopathy after treatment, the predictive factors affecting such unfavourable outcomes are not yet established. We investigated the clinical manifestations and predictors of unfavourable treatment outcomes in patients with spinal TB.

Aims

To address the natural history of severe post-tuberculous (TB) kyphosis, with focus upon the long-term neurological outcome, occurrence of restrictive lung disease, and the effect on life expectancy.

Aims

The aim of this study was to determine the efficacy of repeat epidural steroid injections as a form of treatment for patients with insufficiently controlled or recurrent radicular pain due to a lumbar or cervical disc herniation.

C5 nerve root palsy is a rare and potentially debilitating complication of cervical spine surgery. Currently, however, there are no guidelines to help surgeons to prevent or treat this complication.

We carried out a systematic review of the literature to identify the causes of this complication and options for its prevention and treatment. Searches of PubMed, Embase and Medline yielded 60 articles for inclusion, most of which addressed C5 palsy as a complication of surgery. Although many possible causes were given, most authors supported posterior migration of the spinal cord with tethering of the nerve root as being the most likely.

Early detection and prevention of a C5 nerve root palsy using neurophysiological monitoring and variations in surgical technique show promise by allowing surgeons to minimise or prevent the incidence of C5 palsy. Conservative treatment is the current treatment of choice; most patients make a full recovery within two years.

Cite this article: Bone Joint J 2014;96-B:950–5.

There have been a few reports of patients with a combination of lumbar and thoracic spinal stenosis. We describe six patients who suffered unexpected acute neurological deterioration at a mean of 7.8 days (6 to 10) after lumbar decompressive surgery. Five had progressive weakness and one had recurrent pain in the lower limbs. There was incomplete recovery following subsequent thoracic decompressive surgery.

The neurological presentation can be confusing. Patients with compressive myelopathy due to lower thoracic lesions, especially epiconus lesions (T10 to T12/L1 disc level), present with similar symptoms to those with lumbar radiculopathy or cauda equina lesions. Despite the rarity of this condition we advise that patients who undergo lumbar decompressive surgery for stenosis should have sagittal whole spine MRI studies pre-operatively to exclude proximal neurological compression.

Cite this article: Bone Joint J 2013;95-B:1388–91.

Aim

Many aspects of the surgical treatment of patients with tuberculosis (TB) of the spine, including the use of instrumentation and the types of graft, remain controversial. Our aim was to report the outcome of a single-stage posterior procedure, with or without posterior decompression, in this group of patients.

This study assessed the frequency of acute injury to the spinal cord in Irish Rugby over a period of ten years, between 1995 and 2004. There were 12 such injuries; 11 were cervical and one was thoracic. Ten occurred in adults and two in schoolboys. All were males playing Rugby Union and the mean age at injury was 21.6 years (16 to 36). The most common mechanism of injury was hyperflexion of the cervical spine and the players injured most frequently were playing at full back, hooker or on the wing. Most injuries were sustained during the tackle phase of play. Six players felt their injury was preventable. Eight are permanently disabled as a result of their injury.

This study evaluates factors related to myelopathic symptoms in patients with ossification of the posterior longitudinal ligament (OPLL). A total of 87 patients with OPLL were included. Of these, 53 (Group I) had no symptoms or presented with neck pain and radiculopathy and 34 (Group II) had myelopathic symptoms. Gender, age, and history of trauma were evaluated in the two groups. The range of movement of the cervical spine was measured using plain radiographs. The number of involved segments, type of OPLL, and maximal compression ratio were analysed using CT and signal change in the spinal cord was evaluated using MRI.

The patients’ age was found to be significant (p = 0.001). No difference was found between gender and the range of movement in the two groups. The maximum compression of the spinal canal showed a difference (p = 0.03). The signal change of the spinal cord was different between the two groups. In patients with OPLL of the cervical spine, myelopathic symptoms are not related to the range of movement or the number of involved segments.

We evaluated the efficacy of anterior fusion alone compared with combined anterior and posterior fusion for the treatment of degenerative cervical kyphosis. Anterior fusion alone was undertaken in 15 patients (group A) and combined anterior and posterior fusion was carried out in a further 15 (group B). The degree and maintenance of the angle of correction, the incidence of graft subsidence, degeneration at adjacent levels and the rate of fusion were assessed radiologically and clinically and the rate of complications recorded. The mean angle of correction in group B was significantly higher than in group A (p = 0.0009). The mean visual analogue scale and the neck disability index in group B was better than in group A (p = 0.043, 0.0006). The mean operation time and the blood loss in B were greater than in group A (p < 0.0001, 0.037). Pseudarthrosis, subsidence of the cage, and problems related to the hardware were more prevalent in group A than in group B (p = 0.034, 0.025, 0.013).

Although the combined procedure resulted in a longer operating time and greater blood loss than with anterior fusion alone, our results suggest that for the treatment of degenerative cervical kyphosis the combined approach leads to better maintenance of sagittal alignment, a higher rate of fusion, a lower incidence of complications and a better clinical outcome.

We carried out a prospective study to determine whether the addition of a recombinant human bone morphogenetic protein (rhBMP-2) to a machined allograft spacer would improve the rate of intervertebral body fusion in the spine. We studied 77 patients who were to undergo an interbody fusion with allograft and instrumentation. The first 36 patients received allograft with adjuvant rhBMP-2 (allograft/rhBMP-2 group), and the next 41, allograft and demineralised bone matrix (allograft/demineralised bone matrix group). Each patient was assessed clinically and radiologically both pre-operatively and at each follow-up visit using standard methods. Follow-up continued for two years.

Every patient in the allograft/rhBMP-2 group had fused by six months. However, early graft lucency and significant (> 10%) subsidence were seen radiologically in 27 of 55 levels in this group. The mean graft height subsidence was 27% (13% to 42%) for anterior lumbar interbody fusion, 24% (13% to 40%) for transforaminal lumbar interbody fusion, and 53% (40% to 58%) for anterior cervical discectomy and fusion. Those who had undergone fusion using allograft and demineralised bone matrix lost only a mean of 4.6% (0% to 15%) of their graft height.

Although a high rate of fusion (100%) was achieved with rhBMP-2, significant subsidence occurred in more than half of the levels (23 of 37) in the lumbar spine and 33% (6 of 18) in the cervical spine. A 98% fusion rate (62 of 63 levels) was achieved without rhBMP-2 and without the associated graft subsidence. Consequently, we no longer use rhBMP-2 with allograft in our practice if the allograft has to provide significant structural support.

We reviewed 75 patients (57 men and 18 women), who had undergone tension-band laminoplasty for cervical spondylotic myelopathy (42 patients) or compression myelopathy due to ossification of the posterior longitudinal ligament (33 patients) and had been followed for more than ten years. Clinical and functional results were estimated using the Japanese Orthopaedic Association score. The rate of recovery and the level of postoperative axial neck pain were also recorded. The pre- and post-operative alignment of the cervical spine (Ishihara curve index indicating lordosis of the cervical spine) and the range of movement (ROM) of the cervical spine were also measured.

The mean rate of recovery of the Japanese Orthopaedic Association score at final follow-up was 52.1% (sd 24.6) and significant axial pain was reported by 19 patients (25.3%). Axial pain was reported more frequently in patients with ossification of the posterior longitudinal ligament than in those with cervical spondylotic myelopathy (p = 0.027). A kyphotic deformity was not seen post-operatively in any patient. The mean ROM decreased post-operatively from 32.8° (sd 12.3) to 16.2° (sd 12.3) (p < 0.001). The mean ROM ratio was 46.9% (sd 28.1) for all the patients. The mean ROM ratio was lower in patients with ossification of the posterior longitudinal ligament than in those with cervical spondylotic myelopathy (p < 0.001). Compared to those with cervical spondylotic myelopathy, patients with ossification of the posterior longitudinal ligament had less ROM and more post-operative axial neck pain.

We have examined the outcome in 19 professional rugby union players who underwent anterior cervical discectomy and fusion between 1998 and 2003. Through a retrospective review of the medical records and telephone interviews of all 19 players, we have attempted to determine the likelihood of improvement, return to professional sport and the long-term consequences. We have also attempted to relate the probability of symptoms in the neck and radicular pain in the arm to the position of play. Neck and radicular pain were improved in 17 patients, with 13 returning to rugby, the majority by six months after operation. Of these, 13 returned to their pre-operative standard of play, one to a lower level and five have not played rugby again. Two of those who returned to the game have subsequently suffered further symptoms in the neck, one of whom was obliged to retire. The majority of the players with problems in the neck were front row forwards.

A return to playing rugby union after surgery and fusion of the anterior cervical spine is both likely and safe and need not end a career in the game.