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

In a prospective study between August 2002 and August 2005, we studied the quantitative clinical and radiological outcome 36 months after percutaneous vertebroplasty for intractable type-II osteoporotic vertebral compression fractures which had been unresponsive to conservative treatment for at least eight weeks. We also examined the quality of life (QoL). The clinical follow-up involved the use of a pain intensity numerical rating scale (PI-NRS, 0 to 10), the Short-Form 36 (SF-36) QoL questionnaire and an anamnestic questionnaire before and at seven days (PI-NRS only), and one, three, 12 and 36 months post-operatively. A total of 30 consecutive patients received percutaneous vertebroplasty for 62 vertebral compression fractures with a mean time between fracture and treatment of 7.7 months (2.2 to 39). An immediate, significant and lasting reduction in the average and worst back pain was found, represented by a decrease of 3.1 and 2.7 points after seven days and 3.1 and 2.8 points after 36 months, respectively (p < 0.00). Comparison of the pre- and post-vertebroplasty scores on the various SF-36 domains showed an ultimate significant increase in six of eight domains and both summary scores. Asymptomatic leakage of cement was found in 47 of 58 (81%) of treated vertebrae. Two minor complications occurred, an asymptomatic pulmonary cement embolism and a cement spur along the needle track. Percutaneous vertebroplasty in the treatment of chronic vertebral compression fractures results in an immediate, significant and lasting reduction in back pain, and overall improvement in physical and mental health

We reviewed the outcome of a retrospective case series of eight patients with atlantoaxial instability who had been treated by percutaneous anterior transarticular screw fixation and grafting under image-intensifier guidance between December 2005 and June 2008. The mean follow-up was 19 months (8 to 27). All eight patients had a solid C1–2 fusion. There were no breakages or displacement of screws. All the patients with pre-operative neck pain had immediate relief from their symptoms or considerable improvement. There were no major complications. Our preliminary clinical results suggest that percutaneous anterior transarticulation screw fixation is technically feasible, safe, useful and minimally invasive when using the appropriate instruments allied to intra-operative image intensification, and by selecting the correct puncture point, angle and depth of insertion

We reviewed 15 consecutive patients, 11 women and four men, with a mean age of 48.7 years (37.3 to 62.6), who between July 2004 and August 2007 had undergone percutaneous sacroiliac fusion using hollow modular anchorage screws filled with demineralised bone matrix. Each patient was carefully assessed to exclude other conditions and underwent pre-operative CT and MR scans. The diagnosis of symptomatic sacroiliac disease was confirmed by an injection of local anaesthetic and steroid under image intensifier control. The short form-36 questionnaire and Majeed’s scoring system were used for pre- and post-operative functional evaluation. Post-operative radiological evaluation was performed using plain radiographs. Intra-operative blood loss was minimal and there were no post-operative clinical or radiological complications. The mean follow-up was for 17 months (9 to 39). The mean short form-36 scores improved from 37 (23 to 51) to 80 (67 to 92) for physical function and from 53 (34 to 73) to 86 (70 to 98) for general health (p = 0.037). The mean Majeed’s score improved from 37 (18 to 54) pre-operatively to 79 (63 to 96) post-operatively (p = 0.014). There were 13 good to excellent results. The remaining two patients improved in short form-36 from a mean of 29 (26 to 35) to 48 (44 to 52). Their persistent pain was probably due to concurrent lumbar pathology. We conclude that percutaneous hollow modular anchorage screws are a satisfactory method of achieving sacroiliac fusion

We present the clinical and radiological results of percutaneous vertebroplasty in the treatment of 58 vertebral compression fractures in 51 patients at a minimum follow-up of two years. Group 1 consisted of 39 patients, in whom there was no associated intravertebral cleft, whilst group 2 comprised 12 patients with an intravertebral cleft. The Oswestry disability index (ODI) and visual analogue scale (VAS) scores were recorded prospectively. The radiological evidence of kyphotic deformity, vertebral height, leakage of cement and bone resorption around the cement were studied restrospectively, both before and after operation and at the final follow-up. The ODI and VAS scores in both groups decreased after treatment, but the mean score in group 2 was higher than that in group 1 (p = 0.02 (ODI), p = 0.02 (VAS)). There was a greater initial correction of the kyphosis in group 2 than in group 1, although the difference was not statistically significant. However, loss of correction was greater in group 2. Leakage of cement was seen in 24 (41.4%) of 58 vertebrae (group 1, 32.6% (15 of 46); group 2, 75% (9 of 12)), mainly of type B through the basal vertebral vein in group 1 and of type C through the cortical defect in group 2. Resorption of bone around the cement was seen in three vertebrae in group 2 and in one in group 1. There were seven adjacent vertebral fractures in group 1 and one in group 2. Percutaneous vertebroplasty is an effective treatment for osteoporotic compression fractures with or without an intravertebral cleft. Nonetheless, higher rates of complications related to the cement must be recognised in patients in the presence of an intravertebral cleft

Percutaneous nucleotomy is a relatively new technique for treating lumbar disc herniation. There is no agreement as to the volume of disc material to be removed. A long-term study of clinical and radiological data from patients treated by percutaneous nucleotomy was designed to identify the factors associated with favourable and unfavourable outcomes. We studied 42 patients for at least ten years; the mean follow-up was 10.9 years. They were divided into two subgroups to assess the value of preserving the nucleus pulposus in the central area of the disc. The overall success rate for both subgroups was 50%. A decrease in disc height on plain radiography and a decrease in signal intensity on MRI were observed more infrequently in patients in whom the nucleus pulposus in the central area of the disc had been preserved, than in those in whom it had been extensively removed. These adverse radiological findings correlated closely with increased low back pain during the first one to two years after operation and a poorer overall outcome. We conclude that percutaneous nucleotomy is most likely to be successful when the central area of the disc is preserved

The optimal timing of percutaneous vertebroplasty as treatment for painful osteoporotic vertebral compression fractures (OVCFs) is still unclear. With the position of vertebroplasty having been challenged by recent placebo-controlled studies, appropriate timing gains importance. We investigated the relationship between the onset of symptoms – the time from fracture – and the efficacy of vertebroplasty in 115 patients with 216 painful subacute or chronic OVCFs (mean time from fracture 6.0 months (. sd. 2.9)). These patients were followed prospectively in the first post-operative year to assess the level of back pain and by means of health-related quality of life (HRQoL). We also investigated whether greater time from fracture resulted in a higher risk of complications or worse pre-operative condition, increased vertebral deformity or the development of nonunion of the fracture as demonstrated by the presence of an intravertebral cleft. It was found that there was an immediate and sustainable improvement in the level of back pain and HRQoL after vertebroplasty, which was independent of the time from fracture. Greater time from fracture was associated with neither worse pre-operative conditions nor increased vertebral deformity, nor with the presence of an intravertebral cleft. We conclude that vertebroplasty can be safely undertaken at an appropriate moment between two and 12 months following the onset of symptoms of an OVCF

Aims

The aim of this study was to compare the effect of a percutaneous radiofrequency heat lesion at the medial branch of the primary dorsal ramus with a sham procedure, for the treatment of lumbar facet joint pain.

We investigated the safety and efficacy of treating osteoporotic vertebral compression fractures with an intravertebral cleft by balloon kyphoplasty. Our study included 27 patients who were treated in this way. The mean follow-up was 38.2 months (24 to 54). The anterior and middle heights of the vertebral body and the kyphotic angle were measured on standing lateral radiographs before surgery, one day after surgery, and at final follow-up. Leakage of cement was determined by CT scans. A visual analogue scale and the Oswestry disability index were chosen to evaluate pain and functional activity. Statistically significant improvements were found between the pre- and post-operative assessments (p < 0.05) but not between the post-operative and final follow-up assessments (p > 0.05). Asymptomatic leakage of cement into the paravertebral vein occurred in one patient, as did leakage into the intervertebral disc in another patient.

We suggest that balloon kyphoplasty is a safe and effective minimally invasive procedure for the treatment of osteoporotic vertebral compression fractures with an intravertebral cleft.

We analysed the CT scans and radiographs of 76 vertebrae in 49 patients who underwent vertebroplasty for painful osteoporotic compression fractures. Leaks of cement were classified into three types: those via the basivertebral vein (type B), via the segmental vein (type S), and through a cortical defect (type C).

More leaks were identified on CT scans than on radiographs by a factor of 1.5 (74/49). Most type-B (93%) and type-S (86%) leaks were missed or underestimated on a lateral radiograph which is usually the only view used during the injection of cement. Of the leaks into the spinal canal, only 7% (2/28) were correctly identified on radiographs. The areas on lateral radiographs where this type of leak may be observed were divided into four zones, and their diagnostic value in predicting a leak into the spinal canal was evaluated. The results showed that cement in the neural foramina had the highest positive predictive value (86%).

We undertook a retrospective study investigating the accuracy and safety of percutaneous pedicle screws placed under fluoroscopic guidance in the lumbosacral junction and lumbar spine. The CT scans of patients were chosen from two centres: European patients from University Medical Center Hamburg-Eppendorf, Germany, and Asian patients from the University of Malaya, Malaysia. Screw perforations were classified into grades 0, 1, 2 and 3. A total of 880 percutaneous pedicle screws from 203 patients were analysed: 614 screws from 144 European patients and 266 screws from 59 Asian patients. The mean age of the patients was 58.8 years (16 to 91) and there were 103 men and 100 women. The total rate of perforation was 9.9% (87 screws) with 7.4% grade 1, 2.0% grade 2 and 0.5% grade 3 perforations. The rate of perforation in Europeans was 10.4% and in Asians was 8.6%, with no significant difference between the two (p = 0.42). The rate of perforation was the highest in S1 (19.4%) followed by L5 (14.9%). The accuracy and safety of percutaneous pedicle screw placement are comparable to those cited in the literature for the open method of pedicle screw placement. Greater caution must be taken during the insertion of L5 and S1 percutaneous pedicle screws owing to their more angulated pedicles, the anatomical variations in their vertebral bodies and the morphology of the spinal canal at this location. Cite this article: Bone Joint J 2015; 97-B:1111–17

Aims

The aim of this study was to investigate the impact of the level of upper instrumented vertebra (UIV) in frail patients undergoing surgery for adult spine deformity (ASD).

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The aim of this study was to report the long-term prognosis of patients with multiple Langerhans cell histiocytosis (LCH) involving the spine, and to analyze the risk factors for progression-free survival (PFS).

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The aims of this study were to determine the diagnostic yield of image-guided biopsy in providing a final diagnosis in patients with suspected infectious spondylodiscitis, to report the diagnostic accuracy of various microbiological tests and histological examinations in these patients, and to report the epidemiology of infectious spondylodiscitis from a country where tuberculosis (TB) is endemic, including the incidence of drug-resistant TB.

Vertebral compression fractures are the most prevalent complication of osteoporosis and percutaneous vertebroplasty (PVP) has emerged as a promising addition to the methods of treating the debilitating pain they may cause. Since PVP was first reported in the literature in 1987, more than 600 clinical papers have been published on the subject. Most report excellent improvements in pain relief and quality of life. However, these papers have been based mostly on uncontrolled cohort studies with a wide variety of inclusion and exclusion criteria. In 2009, two high-profile randomised controlled trials were published in the New England Journal of Medicine which led care providers throughout the world to question the value of PVP. After more than two decades a number of important questions about the mechanism and the effectiveness of this procedure remain unanswered

Aims

Open discectomy (OD) is the standard operation for lumbar disc herniation (LDH). Percutaneous endoscopic lumbar discectomy (PELD), however, has shown similar outcomes to OD and there is increasing interest in this procedure. However despite improved surgical techniques and instrumentation, reoperation and infection rates continue and are reported to be between 6% and 24% and 0.7% and 16%, respectively. The objective of this study was to compare the rate of reoperation and infection within six months of patients being treated for LDH either by OD or PELD.

Aims

As the population ages and the surgical complexity of lumbar spinal surgery increases, the preoperative stratification of risk becomes increasingly important. Understanding the risks is an important factor in decision-making and optimizing the preoperative condition of the patient. Our aim was to determine whether the modified five-item frailty index (mFI-5) and nutritional parameters could be used to predict postoperative complications in patients undergoing simple or complex lumbar spinal fusion.

Aims

With recent progress in cancer treatment, the number of advanced-age patients with spinal metastases has been increasing. It is important to clarify the influence of advanced age on outcomes following surgery for spinal metastases, especially with a focus on subjective health state values.

We have studied 58 patients with pain from osteoporotic vertebral fractures which did not respond to conservative treatment. These were 53 women and five men with a mean age of 72.5 years. They received a nerve-root injection with lidocaine, bupivicaine and DepoMedrol. The mean follow-up period was 13.5 months. The mean pain scores before treatment, at one and six months after treatment and at the final follow-up were 85, 24.9, 14.1, and 17.4, respectively. According to our modified criteria for grading results, six patients were considered to have an excellent result, 42 good and ten fair. A newly developed compression fracture was noted in three patients. There were no complications related to the injection. Our study suggests that nerve-root injections are effective in reducing pain in patients with osteoporotic vertebral fractures and that these patients should be considered for this treatment before percutaneous vertebroplasty or operative intervention is attempted

With the identification of literature shortfalls on the techniques employed in intraoperative navigated (ION) spinal surgery, we outline a number of measures which have been synthesised into a coherent operative technique. These include positioning, dissection, management of the reference frame, the grip, the angle of attack, the drill, the template, the pedicle screw, the wire, and navigated intrathecal analgesia. Optimizing techniques to improve accuracy allow an overall reduction of the repetition of the surgical steps with its associated productivity benefits including time, cost, radiation, and safety.

Cite this article: Bone Joint J 2020;102-B(3):371–375.