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).

Aims. People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians’ views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial). Methods. An online cross-sectional survey was piloted by the multidisciplinary research team, then shared with clinical professional groups in the UK who are involved in the management of adults with severe, persistent LBP. The survey had seven sections that covered the demographic details of the clinician, five hypothetical case vignettes of patients with varying presentations, a series of questions regarding the preferred management, and whether or not each clinician would be willing to recruit the example patients into future clinical trials. Results. There were 72 respondents, with a response rate of 9.0%. They comprised 39 orthopaedic spine surgeons, 17 neurosurgeons, one pain specialist, and 15 allied health professionals. Most respondents (n = 61,84.7%) chose conservative care as their first-choice management option for all five case vignettes. Over 50% of respondents reported willingness to randomize three of the five cases to either surgery or BCC, indicating a willingness to participate in the future randomized trial. From the respondents, transforaminal interbody fusion was the preferred approach for spinal fusion (n = 19, 36.4%), and the preferred method of BCC was a combined programme of physical and psychological therapy (n = 35, 48.5%). Conclusion. This survey demonstrates that there is uncertainty about the role of lumbar spine fusion surgery and BCC for a range of example patients with severe, persistent LBP in the UK. Cite this article: Bone Jt Open 2024;5(7):612–620

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.

The April 2024 Spine Roundup. 360. looks at: Lengthening behaviour of magnetically controlled growing rods in early-onset scoliosis: a multicentre study; LDL, cholesterol, and statins usage cause pseudarthrosis following lumbar interbody fusion; Decision-making in the treatment of degenerative lumbar spondylolisthesis of L4/L5; Does the interfacing angle between pedicle screws and support rods affect clinical outcomes after posterior thoracolumbar fusion?; Returning to the grind: how workload influences recovery post-lumbar spine surgery; Securing the spine: a leap forward with s2 alar-iliac screws in adult spinal deformity surgery

The February 2024 Spine Roundup. 360. looks at: Surgeon assessment of bone – any good?; Robotics reduces radiation exposure in some spinal surgery; Interbody fusion cage versus anterior lumbar interbody fusion with posterior instrumentation; Is robotic-assisted pedicle screw placement an answer to the learning curve?; Acute non-traumatic spinal subarachnoid haematomas: a report of five cases and a systematic review of the literature; Is L4-L5 lateral interbody fusion safe and effective?

Aims. The aim of this study was to reassess the rate of neurological, psoas-related, and abdominal complications associated with L4-L5 lateral lumbar interbody fusion (LLIF) undertaken using a standardized preoperative assessment and surgical technique. Methods. This was a multicentre retrospective study involving consecutively enrolled patients who underwent L4-L5 LLIF by seven surgeons at seven institutions in three countries over a five-year period. The demographic details of the patients and the details of the surgery, reoperations and complications, including femoral and non-femoral neuropraxia, thigh pain, weakness of hip flexion, and abdominal complications, were analyzed. Neurological and psoas-related complications attributed to LLIF or posterior instrumentation and persistent symptoms were recorded at one year postoperatively. Results. A total of 517 patients were included in the study. Their mean age was 65.0 years (SD 10.3) and their mean BMI was 29.2 kg/m. 2. (SD 5.5). A mean of 1.2 levels (SD 0.6) were fused with LLIF, and a mean of 1.6 (SD 0.9) posterior levels were fused. Femoral neuropraxia occurred in six patients (1.2%), of which four (0.8%) were LLIF-related and two (0.4%) had persistent symptoms one year postoperatively. Non-femoral neuropraxia occurred in nine patients (1.8%), one (0.2%) was LLIF-related and five (1.0%) were persistent at one year. All LLIF-related neuropraxias resolved by one year. A total of 32 patients (6.2%) had thigh pain, 31 (6.0%) were LLIF-related and three (0.6%) were persistent at one year. Weakness of hip flexion occurred in 14 patients (2.7%), of which eight (1.6%) were LLIF-related and three (0.6%) were persistent at one year. No patients had bowel injury, three (0.6%) had an intraoperative vascular injury (not LLIF-related), and five (1.0%) had ileus. Reoperations occurred in five patients (1.0%) within 30 days, 37 (7.2%) within 90 days, and 41 (7.9%) within one year postoperatively. Conclusion. LLIF involving the L4-L5 disc level has a low rate of persistent neurological, psoas-related, and abdominal complications in patients with the appropriate indications and using a standardized surgical technique. Cite this article: Bone Joint J 2024;106-B(1):53–61

The October 2023 Spine Roundup³⁶⁰ looks at: Cutting through surgical smoke: the science of cleaner air in spinal operations; Unlocking success: key factors in thoracic spine decompression and fusion for ossification of the posterior longitudinal ligament; Deep learning algorithm for identifying cervical cord compression due to degenerative canal stenosis on radiography; Surgeon experience influences robotics learning curve for minimally invasive lumbar fusion; Decision-making algorithm for the surgical treatment of degenerative lumbar spondylolisthesis of L4/L5; Response to preoperative steroid injections predicts surgical outcomes in patients undergoing fusion for isthmic spondylolisthesis.

The June 2023 Spine Roundup³⁶⁰ looks at: Characteristics and comparative study of thoracolumbar spine injury and dislocation fracture due to tertiary trauma; Sublingual sufentanil for postoperative pain management after lumbar spinal fusion surgery; Minimally invasive bipolar technique for adult neuromuscular scoliosis; Predictive factors for degenerative lumbar spinal stenosis; Lumbosacral transitional vertebrae and lumbar fusion surgery at level L4/5; Does recall of preoperative scores contaminate trial outcomes? A randomized controlled trial; Vancomycin in fibrin glue for prevention of SSI; Perioperative nutritional supplementation decreases wound healing complications following elective lumbar spine surgery: a randomized controlled trial.

Aims

The aim of this study was to assess the accuracy of pedicle screw placement, as well as intraoperative factors, radiation exposure, and complication rates in adult patients with degenerative disorders of the thoracic and lumbar spines who have undergone robotic-navigated spinal surgery using a contemporary system.

Aims

To determine the major risk factors for unplanned reoperations (UROs) following corrective surgery for adult spinal deformity (ASD) and their interactions, using machine learning-based prediction algorithms and game theory.

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

To report the outcome of spinal deformity correction through anterior spinal fusion in wheelchair-bound patients with myelomeningocele.

Aims

High-grade dysplastic spondylolisthesis is a disabling disorder for which many different operative techniques have been described. The aim of this study is to evaluate Scoliosis Research Society 22-item (SRS-22r) scores, global balance, and regional spino-pelvic alignment from two to 25 years after surgery for high-grade dysplastic spondylolisthesis using an all-posterior partial reduction, transfixation technique.

Aims. To determine the effectiveness of prone traction radiographs in predicting postoperative slip distance, slip angle, changes in disc height, and lordosis after surgery for degenerative spondylolisthesis of the lumbar spine. Methods. A total of 63 consecutive patients with a degenerative spondylolisthesis and preoperative prone traction radiographs obtained since 2010 were studied. Slip distance, slip angle, disc height, segmental lordosis, and global lordosis (L1 to S1) were measured on preoperative lateral standing radiographs, flexion-extension lateral radiographs, prone traction lateral radiographs, and postoperative lateral standing radiographs. Patients were divided into two groups: posterolateral fusion or posterolateral fusion with interbody fusion. Results. The mean changes in segmental lordosis and global lordosis were 7.1° (SD 6.7°) and 2.9° (SD 9.9°) respectively for the interbody fusion group, and 0.8° (SD 5.1°) and -0.4° (SD 10.1°) respectively for the posterolateral fusion-only group. Segmental lordosis (ρ = 0.794, p < 0.001) corrected by interbody fusion correlated best with prone traction radiographs. Global lumbar lordosis (ρ = 0.788, p < 0.001) correlated best with the interbody fusion group and preoperative lateral standing radiographs. The least difference in slip distance (-0.3 mm (SD 1.7 mm), p < 0.001), slip angle (0.9° (SD 5.2°), p < 0.001), and disc height (0.02 mm (SD 2.4 mm), p < 0.001) was seen between prone traction and postoperative radiographs. Regression analyses suggested that prone traction parameters best predicted correction of slip distance (Corrected Akaike’s Information Criterion (AICc) = 37.336) and disc height (AICc = 58.096), while correction of slip angle (AICc = 26.453) was best predicted by extension radiographs. Receiver operating characteristic (ROC) cut-off showed, with 68.3% sensitivity and 64.5% specificity, that to achieve a 3.0° increase in segmental lordotic angle, patients with a prone traction disc height of 8.5 mm needed an interbody fusion. Conclusion. Prone traction radiographs best predict the slip distance and disc height correction achieved by interbody fusion for lumbar degenerative spondylolisthesis. To achieve this maximum correction, interbody fusion should be undertaken if a disc height of more than 8.5 mm is attained on preoperative prone traction radiographs. Level of Evidence: Level II Prognostic Study. Cite this article: Bone Joint J 2020;102-B(8):1062–1071

Aims

The aim of this paper is to describe the impact of COVID-19 on spine surgery services in a district general hospital in England in order to understand the spinal service provisions that may be required during a pandemic.

Aims. Chronic low back pain due to degenerative disc disease is sometimes treated with fusion. We compared the outcome of three different fusion techniques in the Swedish Spine Register: noninstrumented posterolateral fusion (PLF), instrumented posterolateral fusion (IPLF), and interbody fusion (IBF). Patients and Methods. A total of 2874 patients who were operated on at one or two lumbar levels were followed for a mean of 9.2 years (3.6 to 19.1) for any additional lumbar spine surgery. Patient-reported outcome data were available preoperatively (n = 2874) and at one year (n = 2274), two years (n = 1958), and a mean of 6.9 years (n = 1518) postoperatively and consisted of global assessment and visual analogue scales of leg and back pain, Oswestry Disability Index, EuroQol five-dimensional index, 36-Item Short-Form Health Survey, and satisfaction with treatment. Statistical analyses were performed with competing-risks proportional hazards regression or analysis of covariance, adjusted for baseline variables. Results. The number of patients with additional surgery were 32/183 (17%) in the PLF group, 229/1256 (18%) in the IPLF group, and 439/1435 (31%) in the IBF group. With the PLF group as a reference, the hazard ratio for additional lumbar surgery was 1.16 (95% confidence interval (CI) 0.78 to 1.72) for the IPLF group and 2.13 (95% CI 1.45 to 3.12) for the IBF group. All patient-reported outcomes improved after surgery (p < 0.001) but were without statistically significant differences between the groups at the one-, two- and 6.9-year follow-ups (all p ≥ 0.12). Conclusion. The addition of interbody fusion to posterolateral fusion was associated with a higher risk for additional surgery and showed no advantages in patient-reported outcome. Cite this article: Bone Joint J 2019;101-B:1526–1533

Aims

The aim of this study was to explore risk factors for complications associated with dural tear (DT), including the types of DT, and the intra- and postoperative management of DT.

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.

Aims. We compared the clinical and radiological outcomes of using a polyetheretherketone cage with (TiPEEK) and without a titanium coating (PEEK) for instrumented transforaminal lumbar interbody fusion (TLIF). Materials and Methods. We conducted a randomised clinical pilot trial of 40 patients who were scheduled to undergo a TLIF procedure at one or two levels between L2 and L5. The Oswestry disability index (ODI), EuroQoL-5D, and back and leg pain were determined pre-operatively, and at three, six, and 12 months post-operatively. Fusion rates were assessed by thin slice CT at three months and by functional radiography at 12 months. Results. At final follow-up, one patient in each group had been lost to follow-up. Two patients in each of the PEEK and TiPEEK groups were revised for pseudarthrosis (p = 1.00). The rate of complete or partial fusion at three months was 91.7% in both groups. Overall, there were no significant differences in ODI or in radiological outcomes between the groups. Conclusion. Favourable results with identical clinical outcomes and a high rate of fusion was seen in both groups. The titanium coating appears to have no negative effects on outcome or safety in the short term. A future study to determine the effect of titanium coating is warranted. Cite this article: Bone Joint J 2017;99-B:1366–72

Aims

To evaluate the incidence of primary venous thromboembolism (VTE), epidural haematoma, surgical site infection (SSI), and 90-day mortality after elective spinal surgery, and the effect of two protocols for prophylaxis.

Aims. Minimally invasive transforaminal lumbar interbody fusion (MITLIF) has been well validated in overweight and obese patients who are consequently subject to a higher radiation exposure. This prospective multicentre study aimed to investigate the efficacy of a novel lumbar localisation system for MITLIF in overweight patients. Patients and Methods. The initial study group consisted of 175 patients. After excluding 49 patients for various reasons, 126 patients were divided into two groups. Those in Group A were treated using the localisation system while those in Group B were treated by conventional means. The primary outcomes were the effective radiation dosage to the surgeon and the exposure time. Results. There were 62 patients in Group A and 64 in Group B. The mean effective dosage was 0.0217 mSv (standard deviation (. sd. ) 0.0079) in Group A and 0.0383 mSv (. sd. 0.0104) in Group B (p <  0.001). The mean fluoroscopy exposure time was 26.42 seconds (. sd. 5.91) in Group A and 40.67 seconds (. sd. 8.18) in Group B (p < 0.001). The operating time was 175.56 minutes (. sd. 32.23) and 206.08 minutes (. sd. 30.15) (p < 0.001), respectively. The mean pre-operative localisation time was 4.73 minutes (. sd. 0.84) in Group A and 7.03 minutes (. sd. 1.51) in Group B (p < 0.001). The mean screw placement time was 47.37 minutes (. sd. 10.43) in Group A and 67.86 minutes (. sd. 14.15) in Group B (p < 0.001). The pedicle screw violation rate was 0.35% (one out of 283) in Group A and 2.79% (eight out of 287) in Group B (p = 0.020). Conclusion. The study shows that the localisation system can effectively reduce radiation exposure, exposure time, operating time, pre-operative localisation time, and screw placement time in overweight patients undergoing MITLIF. Cite this article: Bone Joint J 2017;99-B:944–50

Objectives

We performed a systematic review of the literature to determine the safety and efficacy of bone morphogenetic protein (BMP) compared with bone graft when used specifically for revision spinal fusion surgery secondary to pseudarthrosis.

Aims

The purpose of this prospective study was to evaluate the outcomes of coccygectomy for patients with chronic coccydynia.

Objectives

To employ a simple and fast method to evaluate those patients with neurological deficits and misplaced screws in relatively safe lumbosacral spine, and to determine if it is necessary to undertake revision surgery.

We evaluated the impact of lumbar instrumented circumferential fusion on the development of adjacent level vertebral compression fractures (VCFs). Instrumented posterior lumbar interbody fusion (PLIF) has become a popular procedure for degenerative lumbar spine disease. The immediate rigidity produced by PLIF may cause more stress and lead to greater risk of adjacent VCFs. However, few studies have investigated the relationship between PLIF and the development of subsequent adjacent level VCFs.

Between January 2005 and December 2009, a total of 1936 patients were enrolled. Of these 224 patients had a new VCF and the incidence was statistically analysed with other covariants. In total 150 (11.1%) of 1348 patients developed new VCFs with PLIF, with 108 (72%) cases at adjacent segment. Of 588 patients, 74 (12.5%) developed new subsequent VCFs with conventional posterolateral fusion (PLF), with 37 (50%) patients at an adjacent level. Short-segment fusion, female and age older than 65 years also increased the development of new adjacent VCFs in patients undergoing PLIF. In the osteoporotic patient, more rigid fusion and a higher stress gradient after PLIF will cause a higher adjacent VCF rate.

Cite this article: Bone Joint J 2015;97-B:1411–16.

The aim of this study was to determine whether obesity affects pain, surgical and functional outcomes following lumbar spinal fusion for low back pain (LBP).

A systematic literature review and meta-analysis was made of those studies that compared the outcome of lumbar spinal fusion for LBP in obese and non-obese patients. A total of 17 studies were included in the meta-analysis. There was no difference in the pain and functional outcomes. Lumbar spinal fusion in the obese patient resulted in a statistically significantly greater intra-operative blood loss (weighted mean difference: 54.04 ml; 95% confidence interval (CI) 15.08 to 93.00; n = 112; p = 0.007) more complications (odds ratio: 1.91; 95% CI 1.68 to 2.18; n = 43858; p < 0.001) and longer duration of surgery (25.75 mins; 95% CI 15.61 to 35.90; n = 258; p < 0.001). Obese patients have greater intra-operative blood loss, more complications and longer duration of surgery but pain and functional outcome are similar to non-obese patients. Based on these results, obesity is not a contraindication to lumbar spinal fusion.

Cite this article: Bone Joint J 2015;97-B:1395–1404.

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.

The April 2014 Spine Roundup³⁶⁰ looks at: medical treatment for ankylosing spondylitis; unilateral TLIF effective; peg fractures akin to neck of femur fractures; sleep apnoea and spinal surgery; scoliosis in osteogenesis imperfect; paediatric atlanto-occipital dislocation; back pain and obesity: chicken or egg?; BMP associated with lumbar plexus deficit; and just how common is back pain?

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.

The August 2013 Spine Roundup³⁶⁰ looks at: SPECT CT and facet joints; a difficult conversation: scoliosis and complications; time for a paradigm shift? complications under the microscope; minor trauma and cervical injury: a predictable phenomenon?; more costly all round: incentivising more complex operations?; minimally invasive surgery = minimal scarring; and symptomatic lumbar spine stenosis.

The purpose of this study was to determine whether it would be feasible to use oblique lumbar interbody fixation for patients with degenerative lumbar disease who required a fusion but did not have a spondylolisthesis.

A series of CT digital images from 60 patients with abdominal disease were reconstructed in three dimensions (3D) using Mimics v10.01: a digital cylinder was superimposed on the reconstructed image to simulate the position of an interbody screw. The optimal entry point of the screw and measurements of its trajectory were recorded. Next, 26 cadaveric specimens were subjected to oblique lumbar interbody fixation on the basis of the measurements derived from the imaging studies. These were then compared with measurements derived directly from the cadaveric vertebrae.

Our study suggested that it is easy to insert the screws for L1/2, L2/3 and L3/4 fixation: there was no significant difference in measurements between those of the 3-D digital images and the cadaveric specimens. For L4/5 fixation, part of L5 inferior articular process had to be removed to achieve the optimal trajectory of the screw. For L5/S1 fixation, the screw heads were blocked by iliac bone: consequently, the interior oblique angle of the cadaveric specimens was less than that seen in the 3D digital images.

We suggest that CT scans should be carried out pre-operatively if this procedure is to be adopted in clinical practice. This will assist in determining the feasibility of the procedure and will provide accurate information to assist introduction of the screws.

Cite this article: Bone Joint J 2013;95-B:977–82.

The April 2013 Spine Roundup³⁶⁰ looks at: smuggling spinal implants; local bone graft and PLIF; predicting disability with slipped discs; mortality and spinal surgery; spondyloarthropathy; brachytherapy; and fibrin mesh and BMP.

In a retrospective cohort study we compared the clinical outcome and complications, including dysphagia, following anterior cervical fusion for the treatment of cervical spondylosis using either a zero-profile (Zero-P; Synthes) implant or an anterior cervical plate and cage. A total of 83 patients underwent fusion using a Zero-P and 107 patients underwent fusion using a plate and cage. The mean follow-up was 18.6 months (sd 4.2) in the Zero-P group and 19.3 months (sd 4.1) in the plate and cage group. All patients in both groups had significant symptomatic and neurological improvement. There were no significant differences between the groups in the Neck Disability Index (NDI) and visual analogue scores at final follow-up. The cervical alignment improved in both groups. There was a higher incidence of dysphagia in the plate and cage group on the day after surgery and at two months post-operatively. All patients achieved fusion and no graft migration or nonunion was observed.

When compared with the traditional anterior cervical plate and cage, the Zero-P implant is a safe and convenient procedure giving good results in patients with symptomatic cervical spondylosis with a reduced incidence of dysphagia post-operatively.

Cite this article: Bone Joint J 2013;95-B:543–7.

We evaluated the efficacy of Escherichia coli-derived recombinant human bone morphogenetic protein-2 (E-BMP-2) in a mini-pig model of spinal anterior interbody fusion. A total of 14 male mini-pigs underwent three-level anterior lumbar interbody fusion using polyether etherketone (PEEK) cages containing porous hydroxyapatite (HA). Four groups of cages were prepared: 1) control (n = 10 segments); 2) 50 μg E-BMP-2 (n = 9); 3) 200 μg E-BMP-2 (n = 10); and 4) 800 μg E-BMP-2 (n = 9). At eight weeks after surgery the mini-pigs were killed and the specimens were evaluated by gross inspection and manual palpation, radiological evaluation including plain radiographs and micro-CT scans, and histological analysis. Rates of fusion within PEEK cages and overall union rates were calculated, and bone formation outside vertebrae was evaluated. One animal died post-operatively and was excluded, and one section was lost and also excluded, leaving 38 sites for assessment. This rate of fusion within cages was 30.0% (three of ten) in the control group, 44.4% (four of nine) in the 50 μg E-BMP-2 group, 60.0% (six of ten) in the 200 μg E-BMP-2 group, and 77.8% (seven of nine) in the 800 μg E-BMP-2 group. Fusion rate was significantly increased by the addition of E-BMP-2 and with increasing E-BMP-2 dose (p = 0.046). In a mini-pig spinal anterior interbody fusion model using porous HA as a carrier, the implantation of E-BMP-2-loaded PEEK cages improved the fusion rate compared with PEEK cages alone, an effect that was significantly increased with increasing E-BMP-2 dosage. Cite this article: Bone Joint J 2013;95-B:217–23

The October 2012 Spine Roundup. 360. looks at: a Japanese questionnaire at work in Iran; curve progression in degenerative lumbar scoliosis; the cause of foot drop; the issue of avoiding the spinal cord at scoliosis surgery; ballistic injuries to the cervical spine; minimally invasive oblique lumbar interbody fusion; readmission rates after spinal surgery; clinical complications and the severely injured cervical spine; and stabilising the thoracolumbar burst fracture

The June 2012 Spine Roundup³⁶⁰ looks at: back pain; spinal fusion for tuberculosis; anatomical course of the recurrent laryngeal nerve; groin pain with normal imaging; the herniated intervertebral disc; obesity’s effect on the spine; the medicolegal risks of cauda equina syndrome; and intravenous lidocaine use and failed back surgery syndrome.

The April 2012 Spine Roundup³⁶⁰ looks at yoga for lower back pain, spinal tuberculosis, complications of spinal surgery, fusing the subaxial cervical spine, minimally invasive surgery and osteoporotic vertebral fractures, spinal surgery in the over 65s, and pain relief after spinal surgery

Posterior lumbar interbody fusion (PLIF) is indicated for many patients with pain and/or instability of the lumbar spine. We performed 36 PLIF procedures using the patient’s lumbar spinous process and laminae, which were inserted as a bone graft between two vertebral bodies without using a cage. The mean lumbar lordosis and mean disc height to vertebral body ratio were restored and preserved after surgery. There were no serious complications.

These results suggest that this procedure is safe and effective.

Increasing numbers of posterior lumbar fusions are being performed. The purpose of this study was to identify trends in demographics, mortality and major complications in patients undergoing primary posterior lumbar fusion. We accessed data collected for the Nationwide Inpatient Sample for each year between 1998 and 2008 and analysed trends in the number of lumbar fusions, mean patient age, comorbidity burden, length of hospital stay, discharge status, major peri-operative complications and mortality. An estimated 1 288 496 primary posterior lumbar fusion operations were performed between 1998 and 2008 in the United States. The total number of procedures, mean patient age and comorbidity burden increased over time. Hospital length of stay decreased, although the in-hospital mortality (adjusted and unadjusted for changes in length of hospital stay) remained stable. However, a significant increase was observed in peri-operative septic, pulmonary and cardiac complications. Although in-hospital mortality rates did not change over time in the setting of increases in mean patient age and comorbidity burden, some major peri-operative complications increased. These trends highlight the need for appropriate peri-operative services to optimise outcomes in an increasingly morbid and older population of patients undergoing lumbar fusion.

We evaluated the maturation of grafted bone in cases of successful fusion after a one- or two-level posterior lumbar interbody fusion (PLIF) using interbody carbon cages. We carried out a five-year prospective longitudinal radiological evaluation of patients using plain radiographs and CT scans. One year after surgery, 117 patients with an early successful fusion were selected for inclusion in the study. Radiological evaluation of interbody bone fusion was graded on a 4-point scale. The mean grades of all radiological and CT assessments increased in the five years after surgery, and differences compared to the previous time interval were statistically significant for three or four years after surgery. Because the grafted bone continues to mature for three years after surgery, the success of a fusion should not be assessed until at least three years have elapsed. There were no significant differences in the longitudinal patterns of grafted bone maturity between iliac bone and local bone. However, iliac bone grafting may remodel faster than local bone

Recurrence of back or leg pain after discectomy is a well-recognised problem with an incidence of up to 28%. Once conservative measures have failed, several surgical options are available and have been tried with varying degrees of success. In this study, 42 patients with recurrent symptoms after discectomy underwent less invasive posterior lumbar interbody fusion (LI-PLIF). Clinical outcome was measured using the Oswestry Disability Index (ODI), Short Form 36 (SF-36) questionnaires and visual analogue scales for back (VAS-BP) and leg pain (VAS-LP). There was a statistically significant improvement in all outcome measures (p < 0.001). The debate around which procedure is the most effective for these patients remains controversial.

Our results show that LI-PLIF is as effective as any other surgical procedure. However, given that it is less invasive, we feel that it should be considered as the preferred option.

We examined the differences in post-operative functional disability and patient satisfaction between 56 patients who underwent a lumbar fusion at three or more levels for degenerative disease (group I) and 69 patients, matched by age and gender, who had undergone a one or two level fusion (group II). Their mean age was 66 years (49 to 84) and the mean follow-up was 43 months (24 to 65).

The mean pre-operative Oswestry Disability Index (ODI) and visual analogue scale (VAS) for back and leg pain, and the mean post-operative VAS were similar in both groups (p >  0.05), but post-operatively the improvement in ODI was significantly less in group I (40.6%) than in group II (49.5%) (p < 0.001). Of the ten ODI items, patients in group I showed significant problems with lifting, sitting, standing, and travelling (p < 0.05). The most significant differences in the post-operative ODI were observed between patients who had undergone fusion at four or more levels and those who had undergone fusion at less than four levels (p = 0.005). The proportion of patients who were satisfied with their operations was similar in groups I and II (72.7% and 77.0%, respectively) (p = 0.668). The mean number of fused levels was associated with the post-operative ODI (r = 0.266, p = 0.003), but not with the post-operative VAS or satisfaction grade (p > 0.05). Post-operative functional disability was more severe in those with a long-level lumbar fusion, particularly at four or more levels, but patient satisfaction remained similar for those with both long- and short-level fusions.

The presacral retroperitoneal approach for axial lumbar interbody fusion (presacral ALIF) is not widely reported, particularly with regard to the mid-term outcome. This prospective study describes the clinical outcomes, complications and rates of fusion at a follow-up of two years for 26 patients who underwent this minimally invasive technique along with further stabilisation using pedicle screws. The fusion was single-level at the L5-S1 spinal segment in 17 patients and two-level at L4–5 and L5-S1 in the other nine. The visual analogue scale for pain and Oswestry Disability Index scores were recorded pre-operatively and during the 24-month study period. The evaluation of fusion was by thin-cut CT scans at six and 12 months, and flexion-extension plain radiographs at six, 12 and 24 months. Significant reductions in pain and disability occurred as early as three weeks postoperatively and were maintained. Fusion was achieved in 22 of 24 patients (92%) at 12 months and in 23 patients (96%) at 24 months. One patient (4%) with a pseudarthrosis underwent successful revision by augmentation of the posterolateral fusion mass through a standard open midline approach. There were no severe adverse events associated with presacral ALIF, which in this series demonstrated clinical outcomes and fusion rates comparable with those of reports of other methods of interbody fusion

A number of causes have been advanced to explain the destructive discovertebral (Andersson) lesions that occur in ankylosing spondylitis, and various treatments have been proposed, depending on the presumed cause. The purpose of this study was to identify the causes of these lesions by defining their clinical and radiological characteristics.

We retrospectively reviewed 622 patients with ankylosing spondylitis. In all, 33 patients (5.3%) had these lesions, affecting 100 spinal segments. Inflammatory lesions were found in 91 segments of 24 patients (3.9%) and traumatic lesions in nine segments of nine patients (1.4%). The inflammatory lesions were associated with recent-onset disease; a low modified Stoke ankylosing spondylitis spine score (mSASSS) due to incomplete bony ankylosis between vertebral bodies; multiple lesions; inflammatory changes on MRI; reversal of the inflammatory changes and central bony ankylosis at follow-up; and a good response to anti-inflammatory drugs. Traumatic lesions were associated with prolonged disease duration; a high mSASSS due to complete bony ankylosis between vertebral bodies; a previous history of trauma; single lesions; nonunion of fractures of the posterior column; acute kyphoscoliotic deformity with the lesion at the apex; instability, and the need for operative treatment due to that instability.

It is essential to distinguish between inflammatory and traumatic Andersson lesions, as the former respond to medical treatment whereas the latter require surgery.

We examined the reliability of radiological findings in predicting segmental instability in 112 patients (56 men, 56 women) with a mean age of 66.5 years (27 to 84) who had degenerative disease of the lumbar spine. They underwent intra-operative biomechanical evaluation using a new measurement system. Biomechanical instability was defined as a segment with a neutral zone > 2 mm/N. Risk factor analysis to predict instability was performed on radiographs (range of segmental movement, disc height), MRI (Thompson grade, Modic type), and on the axial CT appearance of the facet (type, opening, vacuum and the presence of osteophytes, subchondral erosion, cysts and sclerosis) using multivariate logistic regression analysis with a forward stepwise procedure. The facet type was classified as sagittally orientated, coronally orientated, anisotropic or wrapped.

Stepwise multivariate regression analysis revealed that facet opening was the strongest predictor for instability (odds ratio 5.022, p = 0.009) followed by spondylolisthesis, MRI grade and subchondral sclerosis. Forward stepwise multivariate logistic regression indicated that spondylolisthesis, MRI grade, facet opening and subchondral sclerosis of the facet were risk factors. Symptoms evaluated by the Short-Form 36 and visual analogue scale showed that patients with an unstable segment were in significantly more pain than those without. Furthermore, the surgical procedures determined using the intra-operative measurement system were effective, suggesting that segmental instability influences the symptoms of lumbar degenerative disease.

Patients with Bertolotti’s syndrome have characteristic lumbosacral anomalies and often have severe sciatica. We describe a patient with this syndrome in whom standard decompression of the affected nerve root failed, but endoscopic lumbosacral extraforaminal decompression relieved the symptoms.

We suggest that the intractable sciatica in this syndrome could arise from impingement of the nerve root extraforaminally by compression caused by the enlarged transverse process.

Traumatic unilateral facet dislocation of the lumbosacral junction without fracture or with non-displaced fractures of adjacent vertebrae is extremely rare. We describe a case of a young male who sustained a unilateral facet dislocation of the lumbosacral junction in a motor vehicle accident. The unusual features of this case include an unremarkable physical and neurological examination on presentation and absence of other substantial vertebral or extra-vertebral injuries.

A review of the current literature shows that there is a lack of consensus regarding the treatment of spondylolysis and spondylolisthesis in children and adolescents. Most of the views and recommendations provided in various reports are weakly supported by evidence. There is a limited amount of information about the natural history of the condition, making it difficult to compare the effectiveness of various conservative and operative treatments. This systematic review summarises the current knowledge on spondylolysis and spondylolisthesis and attempts to present a rational approach to the evaluation and management of this condition in children and adolescents.

The post-operative changes in the serum levels of CRP and serum amyloid A (SAA) were investigated prospectively in 106 patients after posterior lumbar interbody fusion. In 96 patients who did not have complications related to infection within the first year after operation, the median levels of CRP before operation and on days 3, 7 and 13 after were 0.02 (0.01 to 0.03), 9.12 (2.36 to 19.82), 1.64 (0.19 to 6.10) and 0.53 (0.05 to 2.94) mg/dl, respectively and for SAA, 2.6 (2.0 to 3.8), 1312.1 (58.0 to 3579.8), 77.3 (1.8 to 478.4), 14.1 (0.5 to 71.9) μg/ml, respectively. The levels on day 3 were the highest for both CRP and SAA and significantly decreased (p < 0.01) by day 7 and day 13.

In regard to CRP, no patient had less than the reference level (0.1 mg/dl) on day 7. In only three had the level decreased to the reference level, while in 93 it was above this on day 13. However, for SAA, the levels became normal on day 7 in 10 cases and on day 13 in 34 cases. The ratios relative to the levels on day 3 were significantly lower for SAA compared with CRP on day 7 and day 13. Of the ten patients with infection in the early stages, the level of CRP decreased slightly but an increase in SAA was observed in six.

We concluded that SAA is better than CRP as a post-operative inflammatory marker.

Fracture of a pedicle is a rare complication of spinal instrumentation using pedicular screws, but it can lead to instability and pain and may necessitate extension of the fusion. Osteosynthesis of the fractured pedicle by cerclage-wire fixation and augmentation of the screw fixation by vertebroplasty or temporary elongation of the fixation, allows stabilisation without sacrifice of the adjacent healthy segment. We describe three patients who developed a fracture of the pedicle in the most caudal instrumented vertebra early after lumbar spinal fusion.

During revision surgery the pedicles were reduced and secured by a soft cerclage wire bilaterally. Fusion was obtained at the site of the primary instrumentation and healing of the pedicles was achieved. Cerclage wiring of the fractured pedicle seems to be safe and avoids permanent extension of the fusion without the sacrifice of an otherwise healthy segment.

In a prospective observational study we compared the two-year outcome of lumbar fusion by a simple technique using translaminar screws (n = 57) with a more extensive method using transforaminal lumbar interbody fusion and pedicular screw fixation (n = 63) in consecutive patients with degenerative disease of the lumbar spine. Outcome was assessed using the validated multidimensional Core Outcome Measures Index. Blood loss and operating time were significantly lower in the translaminar screw group (p < 0.01). The complication rates were similar in each group (2% to 4%). In all, 91% of the patients returned their questionnaire at two-years. The groups did not differ in Core Outcome Measures Index score reduction, 3.6 (. sd. 2.5) (translaminar screws) vs 4.0 (. sd. 2.8) (transforaminal lumbar interbody fusion) (p = 0.39); ‘good’ global outcomes, 78% (translaminar screws) vs 78% (transforaminal lumbar interbody fusion) (p = 0.99) or satisfaction with treatment, 82% (translaminar screws) vs 86% (transforaminal lumbar interbody fusion) (p = 0.52). The two fusion techniques differed markedly in their extent and the cost of the implants, but were associated with almost identical patient-orientated outcomes. Extensive three-point stabilisation is not always required to achieve satisfactory patient-orientated results at two years

We have reviewed our experience in managing 11 patients who sustained an indirect sternal fracture in combination with an upper thoracic spinal injury between 2003 and 2006. These fractures have previously been described as ‘associated’ fractures, but since the upper thorax is an anatomical entity composed of the upper thoracic spine, ribs and sternum joined together, we feel that the term ‘fractures of the upper transthoracic cage’ is a better description. These injuries are a challenge because they are unusual and easily overlooked. They require a systematic clinical and radiological examination to identify both lesions. This high-energy trauma gives severe devastating concomitant injuries and CT with contrast and reconstruction is essential after resuscitation to confirm the presence of all the lesions. The injury level occurs principally at T4–T5 and at the manubriosternal joint. These unstable fractures need early posterior stabilisation and fusion or, if treated conservatively, a very close follow-up.

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.

Between March 2000 and February 2006, we carried out a prospective study of 100 patients with a low-grade isthmic spondylolisthesis (Meyerding grade II or below), who were randomised to receive a single-level and instrumented posterior lumbar interbody fusion with either one or two cages. The minimum follow-up was for two years. At this stage 91 patients were available for review. A total of 47 patients received one cage (group 1) and 44 two cages (group 2). The clinical and radiological outcomes of the two groups were compared.

There were no significant differences between the two groups in terms of post-operative pain, Oswestry Disability Score, clinical results, complication rate, percentage of post-operative slip, anterior fusion rate or posterior fusion rate. On the other hand, the mean operating time was 144 minutes (100 to 240) for patients in group 1 and 167 minutes (110 to 270) for those in group 2 (p = 0.0002). The mean blood loss up to the end of the first post-operative day was 756 ml (510 to 1440) in group 1 and 817 ml (620 to 1730) in group 2 (p < 0.0001).

Our results suggest that an instrumented posterior lumbar interbody fusion performed with either one or two cages in addition to a bone graft around the cage has a low rate of complications and a high fusion rate. The clinical outcomes were good in most cases, regardless of whether one or two cages had been used.

Inflammatory markers such as the C-reactive protein (CRP), white blood cell count and body temperature are easy to measure and are used as indicators of infection. The way in which they change in the early post-operative period after instrumented spinal surgery has not been reported in any depth.

We measured these markers pre-operatively and at one, four, seven and 14 days postoperatively in 143 patients who had undergone an instrumented posterior lumbar interbody fusion.

The CRP proved to be the only sensitive marker and had returned to its normal level in 48% of patients after 14 days. The CRP on day 7 was never higher than that on day 4. Age, gender, body temperature, operating time and blood loss were not related to the CRP level. A high CRP does not in itself suggest infection, but any increase after four days may presage infection.

Anterior debridement, grafting of the defect and posterior instrumentation as a single-stage procedure is a controversial method of managing pyogenic vertebral osteomyelitis. Between 1994 and 2005, 37 patients underwent this procedure at our hospital, of which two died and three had inadequate follow-up. The remaining 32 were reviewed for a mean of 36 months (12 to 66). Their mean age was 48 years (17 to 68). A significant pre-operative neurological deficit was present in 13 patients (41%). The mean duration of surgery was 285 minutes (240 to 360) and the mean blood loss was 900 ml (300 to 1600). Pyogenic organisms were isolated in 21 patients (66%). All patients began to mobilise on the second post-operative day. The mean hospital stay was 13.6 days (10 to 20). Appropriate antibiotics were administered for 10 to 12 weeks. Early wound infection occurred in four patients (12.5%), and late infection in two (6.3%). At final follow-up, the infection had resolved in all patients, neurological recovery was seen in ten of 13 (76.9%) and interbody fusion had occurred in 30 (94%). The clinical outcome was excellent or good in 30 patients according to Macnab’s criteria. This surgical protocol can be used to good effect in patients with pyogenic vertebral osteomyelitis when combined with appropriate antibiotic therapy

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.

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

There are few reports on the treatment of pyogenic lumbar spondylodiscitis through the posterior approach using a single incision. Between October 1999 and March 2003 we operated on 18 patients with pyogenic lumbar spondylodiscitis. All underwent posterior lumbar interbody fusion using an autogenous bone graft from the iliac crest and pedicle screws via a posterior approach. The clinical outcome was assessed using the Frankel neurological classification and the criteria of Kirkaldy-Willis. Under the Frankel classification, two patients improved by two grades (C to E), 11 by one grade, and five showed no change. The Kirkaldy-Willis functional outcome was excellent in five patients, good in ten and fair in three. Bony union was confirmed six months after surgery in 17 patients, but in one patient this was not achieved until two years after operation. The mean lordotic angle before operation was 20° (−2° to 42°) and the mean lordotic angle at the final follow-up was 32.5° (17° to 44°). Two patients had a superficial wound infection and two a transient root injury. Posterior lumbar interbody fusion with an autogenous iliac crest bone graft and pedicle screw fixation via a posterior approach can provide satisfactory results in pyogenic spondylodiscitis.

We conducted a prospective, randomised study of 42 cervical interbody fusions undertaken with either an autologous tricortical graft or a cage. The factors assessed in the two groups were: (1) time taken to achieve fusion; (2) neck disability index; (3) pain score; (4) interbody height ratio; (5) interbody angle and (6) the influence of smoking on fusion. No statistical difference was seen in the time taken to achieve fusion, neck disability index, interbody height ratio, or interbody angles. Smoking did not have any effect on the fusion process. The pain score was significantly lower in the tricortical graft group at six months. We conclude that both methods of fusion give similar results, although tricortical graft fusion is cheaper than cage fusion, and is more effective in reducing the pain score

Spines are often stabilised posteriorly by internal fixation and anteriorly by a bone graft. The effect of an autologous bone graft from the iliac crest on implant loads is unknown. We used an internal spinal fixation device with telemetry to measure implant loads for several body positions and activities in nine patients before and after anterior interbody fusion. With the body upright, implant loads were often higher after than before fusion using a bone graft. Distraction of the bridged region led to high implant loads in patients with a fractured vertebra and to marked changes in load in those with degenerative instability. Leaving the lower of the bridged intervertebral discs intact led to only small changes in fixator load after anterior interbody fusion. A bone graft alone does not guarantee a reduction of implant loads

It has been thought that lumbar intervertebral discs were innervated segmentally. We have previously shown that the L5-L6 intervertebral disc in the rat is innervated bilaterally from the L1 and L2 dorsal root ganglia through the paravertebral sympathetic trunks, but the pathways between the disc and the paravertebral sympathetic trunks were unknown. We have now studied the spines of 17 rats to elucidate the exact pathways. We examined serial sections of the lumbar spine using immunohistochemistry for calcitonin gene-related peptide, a sensory nerve marker. We showed that these nerve fibres from the intervertebral disc ran through the sinuvertebral nerve into the rami communicantes, not into the corresponding segmental spinal nerve. In the rat, sensory information from the lumbar intervertebral discs is conducted through rami communicantes. If this innervation pattern applies to man, simple decompression of the corresponding nerve root will not relieve discogenic pain. Anterior interbody fusion, with the denervation of rami communicantes, may be effective for such low back pain

Between 1978 and 1988 a total of 27 operations were performed on 26 patients for cervical myelopathy due to rheumatoid disease in the subaxial spine. Three different causes were recognised: the first group had cord compression due to subluxation of the cervical spine itself (6 patients); the second had cord compression occurring from in front, with rheumatoid lesions of vertebral bodies or discs (6); the third had compression from behind the cord due to granulation tissue within the epidural space (14). Group I was treated by closed reduction of the subluxation followed by surgical fusion either from in front or behind. Group II was decompressed by subtotal resection of the involved vertebral bodies and discs, followed by interbody fusion. The patients in group III were decompressed by laminectomy and excision of fibrous granulation tissue from the epidural space. Good recovery of neurological function was observed after 18 of the operations, fair recovery after five, poor recovery followed three, and one was worse. Myelopathy recurred in four patients, all of whom had had anterior interbody fusion

We compared retrospectively consecutive series of patients with cervical dislocation treated at two Australian centres. In Perth, 82 patients were treated by closed reduction and postural nursing. In Adelaide, 85 patients had closed reduction and early surgical stabilisation by interbody fusion. There were 46 bilateral dislocations, 101 unilateral dislocations, and 20 anterior subluxations. On admission 30 patients had complete tetraplegia, 17 incomplete tetraplegia, and 120 had minimal or no neurological loss. Our results indicated that closed manipulation under general anaesthesia is a safe and effective means of reduction in the acute stage. There was a high mortality rate for acute surgery in patients with complete tetraplegia. Early surgical stabilisation by dowel fusion reduced bed and hospital stay in patients with no neurological loss, but seemed to impair neurological recovery in patients with a neurological deficit on admission. Conservative management after reduction of bilateral dislocation or anterior subluxation led to a higher incidence of instability in patients with minimal or no neurological loss; in such cases surgery to stabilise the injured segment is indicated

We present a study of 30 fusion operations in 26 rheumatoid arthritics with cervical spine instability. Atlanto-axial instability was present in 15, of whom 12 were fused; three had cord involvement and all made a partial or complete recovery following fusion. Cranial settling necessitated cranio-cervical fusion in four patients; all fused, and one with myelopathy was relieved. Subaxial instability required fusion in seven cases; two postoperative deaths followed the only two anterior interbody fusions. Posterior fusion was successful in the other five, with remission of neurological compromise in the three with myelopathy and one with radiculopathy. We conclude that neurological compromise in an unstable but mobile rheumatoid cervical spine can usually be brought to remission by immobilisation alone, so decompressive procedures are unnecessary in the first instance

Persistent back pain in the presence of an intact posterior fusion is commonly seen and is often regarded as being psychogenic in origin. This paper discusses five patients, all of whom were chronically disabled by such pain; all five had a confirmed posterior and/or lateral fusion. In each case lateral discography identified the disc within the fused segment as the source of symptoms and pain relief was obtained with an anterior interbody fusion. This source of pain should be considered as a possibility in similar cases of failed back surgery

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

Assessment of bony union after anterior fusion of the lumbar spine has previously relied on the skilled interpretation of plain radiograph. A biplanar radiographic technique was used to measure small movements between vertebrae and to give a quantitative measure of bony union in 11 patients who had undergone interbody fusion with autogenous bone chips at one level in the lumbar spine. The investigation gave three types of results: bony union, where the fused level showed marked restriction of movement relative to the rest of the lumbar spine; paradoxical movement, where the fused joint showed marked reverse movement (when the patient flexed, the fused level of the lumbar spine extended) which was thought to be due to an anterior bony bar which caused an altered pattern of movement; and non-union, where the level of fusion showed no restriction of movement. The intervertebral joint above the level of fusion was shown to move more than the other joints in the lumbar spine. The study showed that bony union is possible with the use of autogenous cancellous bone chips, and that biplanar radiographic technique can determine the extent of union

A series of 123 patients suffering traumatic spondylolisthesis of the axis is reported. This lesion is associated with extension and axial loading injury, and there is a high incidence of injuries of the face or scalp and of associated fractures of the upper cervical spine. There is a low incidence of neurological injury, which seems paradoxical in the presence of what appears to be gross instability, but protection from extremes of flexion and extension may be adequate treatment. Union is usual regardless of displacement. Traction is a safe means of treatment, but early waking in a halo support reduces time in hospital without jeopardizing the result. Operation is needed only for chronic instability with or without pain, and anterior interbody fusion of C2--3 is than preferred in order to preserve rotation at the atlanto-axial joints

1. Anterior transperitoneal lumbar fusion is a successful method of stabilising painful mechanical derangements which have not responded to the usual conservative measures. 2. The operation in this series was done mainly for backache; it should not be contemplated if there is definite evidence of nerve root compression, because sequestrated disc material cannot be removed from the spinal canal from the anterior route. 3. Careful technique has resulted in few complications attributable to the operation. 4. This method is sometimes thought to be inapplicable in cases of spondylolisthesis with a displacement of more than one-third. However, in this series we have seen the block type of graft used with a good measure of clinical and radiological success. 5. There is no doubt that for those patients who have had previous unsuccessful laminectomies or posterior fusions anterior interbody fusion offers an excellent prospect of recovery

1. At the present stage of our experience, when 150 patients have been analysed over a period of five years, the conclusion has been reached that anterior interbody fusion in the lower lumbar spine is a procedure which should be added to our surgical armamentarium for use in selected cases. 2. Patients suffering from chronic intervertebral disc degeneration whose main symptoms are recurrent incapacitating backache derive the most benefit from this procedure. 3. When used as a salvage operation in patients who have had previous unsuccessful laminectomy or posterior fusion, good results can be expected. 4. In patients with spondylolisthesis anterior interbody fusion should be confined to cases in which the vertebral bodies have not slipped forward more than one-third