1. In this analysis of forty-three patients with syringomyelia, twenty-seven (63 per cent) had scoliosis. This association is probably due to the early involvement of the ventro-medial and dorso-medial nuclei of the spinal cord by expanding lesions. 2. The literature makes no reference to the treatment of scoliosis associated with syringomyelia. Two cases are presented of attempts to correct this scoliosis–one because of increasing deformity, the other for increasing backache. 3. Due to the presence of cystic lesions characteristic of syringomyelia, corrective operative treatment of scoliosis may present an added risk. 4. Because of the high incidence of scoliosis in patients with syringomyelia, any patient with scoliosis should be examined for evidence of neurological deficit

Early decompression in Pott's paraplegia gives encouraging results. It produces speedy recovery from paraplegia and ensures rapid healing of the lesion. Lateral extrapleural decompression without fusion for lesions of thoracic vertebrae is safe and satisfactory. It gives adequate exposure of the anterior and posterior parts of the vertebral bodies and of the theca, without endangering the stability of the spine. Age, sex and site of the lesion have no influence on the prognosis, whereas paraplegia of longer duration, paraplegia in flexion, and paraplegia presenting as a spinal cord tumour carry a bad prognosis. In early lesions there is reconstitution of vertebral bodies whereas in advanced lesions there is consolidation or bony fusion

We treated 31 patients aged 65 years or more with cervical spondylotic myelopathy by microsurgical decompression and fusion at a single most appropriate level, in spite of MRI evidence of compression at several levels. Spinal cord potentials evoked at operation localised the level responsible for the principal lesion at C3-4 in 18 patients, C4-5 in 11 and at C5-6 in two. Despite the frequent coexistence of other age-related conditions, impairing ability to walk, the average Nurick grade improved from 3.5 before operation to 2.2 at a mean follow-up of 48 months. There was also good recovery of finger dexterity and sensitivity. Operation at a single optimal level, as opposed to several, has the advantage of minimising complications, of particular importance in this age group

We performed a retrospective review of 27 scoliotic patients with syringomyelia using MRI. Their mean age at the first MRI examination was 10.9 years, and at the final review 15.8 years. The mean ratio of the diameter of the syrinx to the cord on the midsagittal MRI (S/C ratio) decreased from 0.49 to 0.24; 14 patients showed a decrease of 50% or more (reduction group). In this reduction group, the cerebellar tonsillar herniation decreased from a mean of 11.3 mm to 6.0 mm, and some improvement in dissociated sensory disturbance was seen in nine of 13 patients. The scoliosis improved by 5° or more in six patients in the reduction group. Our results indicate that spontaneous shrinkage of syringomyelia in children is not unusual and is associated with improvement in the tonsillar herniation, the scoliosis and the neurological deficit

Four cases are described of solitary spinal neurofibroma, a rare tumour of the spinal cord or nerve roots. Computerised tomography provided an accurate topographical definition of the tumour. Magnetic resonance imaging showed an increased T2-weighted signal and multiple areas of decreased T1- and T2-weighted signals centrally. The MR signals matched the histological examination which showed hyperplastic interfascicular connective tissue, pleomorphic cells, and tightly packed nerve fibres compressed by the surrounding loose connective tissue. Electron microscopy showed three types of cell: Schwann cells, fibroblast-like cells, and mast cells. The histological findings suggests that solitary spinal neurofibroma is a distinct pathological entity which could be diagnosed preoperatively from the MR images

Ossification of the ligamentum flavum and secondary spinal-cord compression were produced experimentally in mice by implanting bone morphogenetic protein (BMP) in the lumbar extradural space. The ligamentum flavum became hypertrophied and ossified, and protruded into the spinal canal. The thickness of the ossified ligament increased gradually with time, leading to compression and deformation of the spinal cord which showed various degrees of degeneration. Demyelination occurred in the posterior and lateral white columns and neuronal loss or chromatolysis in the grey matter. The pathological findings in the experimental animals closely resemble those found in the human disease and suggest that BMP may be a causative factor of ossification of the ligamentum flavum in man. This experimental model may be useful for the study of myelopathy caused by gradual spinal-cord compression

Progressive structural scoliosis in growing rabbits has been produced. Tethering the thoracic spine into the form of an asymmetric lordosis produces a slowly progressive structural scoliosis by purely mechanical means. The addition of a contralateral release of the paraspinal muscles leads to a very progressive deformity with early cardiorespiratory failure. This release, however, was performed with an electric soldering iron and subsequent study showed that in those animals with severe progressive deformity there was localised spinal cord damage. We suggest that it is this neural damage and not the muscle release which leads to rapid progression. The clinical implications are important in that neurological dysfunction seems to render the spinal column less able to resist mechanical buckling and may be the crucial factor differentiating severely progressive from more benign curves

Informed consent is a very important part of surgical treatment. In this paper, we report a number of legal judgements in spinal surgery where there was no criticism of the surgical procedure itself. The fault that was identified was a failure to inform the patient of alternatives to, and material risks of, surgery, or overemphasizing the benefits of surgery. In one case, there was a promise that a specific surgeon was to perform the operation, which did not ensue. All of the faults in these cases were faults purely of the consenting process. In many cases, the surgeon claimed to have explained certain risks to the patient but was unable to provide proof of doing so. We propose a checklist that, if followed, would ensure that the surgeon would take their patients through the relevant matters but also, crucially, would act as strong evidence in any future court proceedings that the appropriate discussions had taken place. Although this article focuses on spinal surgery, the principles and messages are applicable to the whole of orthopaedic surgery.

Cite this article: Bone Joint J 2019;101-B:355–360.

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

Seventy-two posterior psoas transfer operations performed in forty-four children with lumbar myelomeningocele were reviewed one to eight years after operation in an attempt to assess its value. Muscle charting, an objective recording of the child's walking ability, and radiographic examination of the hips were done. Hip stability was improved: 49 per cent were stable at the time of psoas transfer and 94 per cent at review. Functional results depended mainly on the level of neurological activity present: 57 per cent of the children had an acceptable functional result. Usually, posterior psoas transfer should be done as soon after the age of nine months as the child's condition will allow. Over the age of two years it should be restricted to children with activity in the third and fourth segments of the lumbar cord

1. A forty-nine-year-old man had a chondrosarcoma arising from the body of the seventh thoracic vertebra. The tumour protruded into the mediastinum and also into the spinal canal where it displaced the spinal cord. 2. At operation all the seventh thoracic vertebra and parts of the sixth and eighth were removed together with the tumour. The thoracic spine was reconstructed by inserting two iliac bone-blocks between the cut bodies of the sixth and eighth vertebrae and by wiring two strong "A. O." plates to the transverse processes of the third to the sixth and the eighth to the tenth vertebrae. 3. The patient was nursed in a plaster-of-Paris bed for three and a half months. 4. One year and three months after operation, the patient was walking and well, with no signs of recurrence or metastasis. Radiographs showed that a block-vertebra had been created from the iliac grafts and the two cut vertebrae

1. The clinical experience of fourteen cases of traumatic spondylolisthesis of the axis is described. 2. Evidence is presented which suggests that vertical compression and extension forces are frequently involved. 3. Treatment is based on recognition of the deforming force and its extent. 4. Primary treatment of unstable lesions by the coronally placed bone dowel of Barbour allows early stabilisation and long-term security. 5. The increased antero-posterior diameter of the axis explains the low incidence of spinal cord damage. 6. Skull traction is considered illogical in that it runs parallel in effect to the most deadly form of judicial hanging. 7. Secondary stability following injury may allow continuing force to fracture the spine at other levels. 8. The paradox of an extension injury between the second and third cervical vertebrae and a "flexion" injury at a lower level is discussed

1. Thirteen cases of occipito-cervical fusion performed in the past fifteen years at the London Hospital are described. 2. Seven of the patients had congenital anomalies in the region of the foramen magnum, six had spontaneous atlanto-axial dislocations, and in one case the operation was performed prophylactically to stabilise a severely disorganised cervical spine. 3. Nine of the patients had evidence of neurological involvement before operation due to pressure on the spinal cord or nerve roots. 4. Operative fusion was successful in all cases and there was no operative mortality. 5. The clinical results were good in eight cases and four patients were improved. The condition of one patient, in whom progressive disseminated sclerosis was also present, deteriorated. 6. The technique of operation is described, and it is recommended that it should always be performed as a combined orthopaedic and neurosurgical procedure

We studied degenerative changes in the cervical intervertebral discs of 497 asymptomatic subjects by MRI and evaluated disc degeneration by loss of signal intensity, posterior and anterior disc protrusion, narrowing of the disc space and foraminal stenosis. In each subject, five disc levels from C2–C3 to C6–C7 were evaluated. The frequency of all degenerative findings increased linearly with age. Disc degeneration was the most common observation, being present in 17% of discs of men and 12% of those of women in their twenties, and 86% and 89% of discs of both men and women over 60 years of age. We found significant differences in frequency between genders for posterior disc protrusion and foraminal stenosis. The former, with demonstrable compression of the spinal cord, was observed in 7.6% of subjects, mostly over 50 years of age. Our results should be taken into account when interpreting the MRI findings in patients with symptomatic disorders of the cervical spine

Posterior cervical wiring is commonly performed for patients with spinal instability, but has inherent risks. We report eight patients who had neurological deterioration after sublaminar or spinous process wiring of the cervical spine; four had complete injuries of the spinal cord, one had residual leg spasticity and three recovered after transient injuries. We found no relation between the degree of spinal canal encroachment and the severity of the spinal-cord injury, but in all cases neurological worsening appeared to have been caused by either sublaminar wiring or spinous process wiring which had been placed too far anteriorly. Sublaminar wiring has substantial risks and should be used only at atlantoaxial level, and then only after adequate reduction. Fluoroscopic guidance should be used when placing spinous process wires especially when the posterior spinal anatomy is abnormal

Aims

It is uncertain whether instrumented spinal fixation in nonambulatory children with neuromuscular scoliosis should finish at L5 or be extended to the pelvis. Pelvic fixation has been shown to be associated with up to 30% complication rates, but is regarded by some as the standard for correction of deformity in these conditions. The incidence of failure when comparing the most caudal level of instrumentation, either L5 or the pelvis, using all-pedicle screw instrumentation has not previously been reported. In this retrospective study, we compared nonambulatory patients undergoing surgery at two centres: one that routinely instrumented to L5 and the other to the pelvis.

The fine structure of palmar fascia from patients with Dupuytren's contracture (DC) was compared with that from patients with carpal tunnel syndrome (CTS). In contrast to previous assumptions, the ultrastructure of fibroblasts both in vivo and in vitro from DC and CTS appeared identical, indicating that myofibroblasts are not specific to DC. The major differences between DC and CTS were: 1) a sixfold and fortyfold increase in fibroblast density in cord and nodular areas of DC compared with CTS; 2) a more disorganised pattern of collagen fibrils in DC; and 3) markedly narrowed microvessels surrounded by thickened, laminated basal laminae and proliferating fibroblasts in DC compared with CTS. To account for these morphological changes a hypothesis is presented which proposes that oxygen-free radicals cause pericytic necrosis and fibroblastic proliferation. This hypothesis provides a potential avenue for therapy of DC and other fibrotic conditions

We have reviewed 32 patients with rheumatoid disease of the cervical spine who underwent a total of 40 operations aimed at correcting instability and improving any associated neurovascular deficit. Apart from four patients with intractable pain, the main indication for surgery was progressive neurological impairment. Of the 32 primary operations, 19 (60%) were successful; the remainder failed to achieve their objective and there were two deaths in the immediate postoperative period. Of eight secondary operations performed for recurrence of symptoms or failure to relieve cervical myelopathy, only four were successful. Of nine operations for bony decompression to relieve cord compression from irreducible subluxation, only four were successful. The overall results show a success rate of 57% and a failure rate of 35% with early operative mortality in 8%. Indications for operation are discussed and earlier diagnosis is considered to be the key to improved results

Forty patients with tuberculosis of the lower cervical spine (second to seventh cervical vertebrae) have been reviewed. Pain and stiffness were important and dominant symptoms. Two types of disease were recognised. In children under 10 years old involvement was extensive and diffuse with the formation of large abscesses. In patients over 10 the disease was localised and produced less pus, but was associated with a much higher incidence of Pott's paraplegia. The overall incidence of cord compression was 42.5 per cent (17 out of 40); 13 of the 16 patients with the "adult" type of disease had this complication. The commonest method of treatment was with antituberculous drugs, anterior excision of diseased bone and grafting. This regime rapidly relieved pain, compressive respiratory symptoms due to abscesses and Pott's paraplegia. It also corrected kyphotic deformities from an average of 25.5 degrees to 5.4 degrees