This is a prospective randomised study comparing the clinical and radiological outcomes of uni- and bipedicular balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures. A total of 44 patients were randomised to undergo either uni- or bipedicular balloon kyphoplasty. Self-reported clinical assessment using the Oswestry Disability Index, the Roland-Morris Disability questionnaire and a visual analogue score for pain was undertaken pre-operatively, and at three and twelve months post-operatively. The vertebral height and kyphotic angle were measured from pre- and post-operative radiographs. Total operating time and the incidence of cement leakage was recorded for each group.

Both uni- and bipedicular kyphoplasty groups showed significant within-group improvements in all clinical outcomes at three months and twelve months after surgery. However, there were no significant differences between the groups in all clinical and radiological outcomes. Operating time was longer in the bipedicular group (p < 0.001). The incidence of cement leakage was not significantly different in the two groups (p = 0.09).

A unipedicular technique yielded similar clinical and radiological outcomes as bipedicular balloon kyphoplasty, while reducing the length of the operation. We therefore encourage the use of a unipedicular approach as the preferred surgical technique for the treatment of osteoporotic vertebral compression fractures.

Cite this article: Bone Joint J 2013;95-B:401–6.

Aims

There is a paucity of information on the pre-operative coronal imbalance in patients with degenerative lumbar scoliosis (DLS) and its influence on surgical outcomes.

Few studies have examined the order in which a spinal osteotomy and total hip replacement (THR) are to be performed for patients with ankylosing spondylitis. We have retrospectively reviewed 28 consecutive patients with ankylosing spondylitis who underwent both a spinal osteotomy and a THR from September 2004 to November 2012. In the cohort 22 patients had a spinal osteotomy before a THR (group 1), and six patients had a THR before a spinal osteotomy (group 2). The mean duration of follow-up was 3.5 years (2 to 9). The spinal sagittal Cobb angle of the vertebral osteotomy segment was corrected from a pre-operative kyphosis angle of 32.4 (SD 15.5°) to a post-operative lordosis 29.6 (SD 11.2°) (p < 0.001). Significant improvements in pain, function and range of movement were observed following THR. In group 2, two of six patients had an early anterior dislocation. The spinal osteotomy was performed two weeks after the THR. At follow-up, no hip has required revision in either group. Although this non-comparative study only involved a small number of patients, given our experience, we believe a spinal osteotomy should be performed prior to a THR, unless the deformity is so severe that the procedure cannot be performed.

Cite this article: Bone Joint J 2014;96-B:360–5.

Aims

We undertook a prospective non-randomised radiological study to evaluate the preliminary results of using magnetically-controlled growing rods (MAGEC System, Ellipse technology) to treat children with early-onset scoliosis.

The December 2014 Spine Roundup³⁶⁰ looks at: surgeon outcomes;

complications and scoliosis surgery; is sequestrectomy enough in lumbar disc prolapse?; predicting outcomes in lumbar disc herniation; sympathectomy has a direct effect on the dorsal root ganglion; and distal extensions of fusion in adolescent idiopathic scoliosis.

This review of the literature presents the current understanding of Scheuermann’s kyphosis and investigates the controversies concerning conservative and surgical treatment. There is considerable debate regarding the pathogenesis, natural history and treatment of this condition. A benign prognosis with settling of symptoms and stabilisation of the deformity at skeletal maturity is expected in most patients. Observation and programmes of exercise are appropriate for mild, flexible, non-progressive deformities. Bracing is indicated for a moderate deformity which spans several levels and retains flexibility in motivated patients who have significant remaining spinal growth.

The loss of some correction after the completion of bracing with recurrent anterior vertebral wedging has been reported in approximately one-third of patients. Surgical correction with instrumented spinal fusion is indicated for a severe kyphosis which carries a risk of progression beyond the end of growth causing cosmetic deformity, back pain and neurological complications. There is no consensus on the effectiveness of different techniques and types of instrumentation. Techniques include posterior-only and combined anteroposterior spinal fusion with or without posterior osteotomies across the apex of the deformity. Current instrumented techniques include hybrid and all-pedicle screw constructs.

The October 2012 Spine Roundup³⁶⁰ 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.

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.

There is a high risk of the development of avascular necrosis of the femoral head and nonunion after the treatment of displaced subcapital fractures of the femoral neck in patients aged < 50 years. We retrospectively analysed the results following fixation with two cannulated compression screws and a vascularised iliac bone graft. We treated 18 women and 16 men with a mean age of 38.5 years (20 to 50) whose treatment included the use of an iliac bone graft based on the ascending branch of lateral femoral circumflex artery. There were 20 Garden grade III and 14 grade IV fractures. Clinical and radiological outcomes were evaluated. The mean follow-up was 5.4 years (2 to 10). In 30 hips (88%) union was achieved at a mean of 4.4 months (4 to 6). Nonunion occurred in four hips (12%) and these patients had a mean age of 46.5 years (42 to 50) and underwent revision to a hip replacement six months after operation. The time to union was dependent on age with younger patients achieving earlier union (p < 0.001). According to the Harris hip score which was available for 27 of the 30 hips with satisfactory union, excellent results were obtained in 15 (score ≥ 90 points), fair in ten (score 80 to 90 points), and poor in two hips (≤ 80 points). One patient aged 48 years developed avascular necrosis of femoral head six years after operation and underwent total hip replacement.

The management of displaced subcapital fractures of the femoral neck, in patients aged <  50 years, with two cannulated compression screws and an iliac bone graft based on the ascending branch of lateral femoral circumflex artery, gives satisfactory results with a low rate of complication including avascular necrosis and nonunion.

Cite this article: Bone Joint J 2014;96-B:1024–8.

Diastematomyelia is a rare congenital abnormality of the spinal cord. This paper summarises more than 30 years’ experience of treating this condition. Data were collected retrospectively on 138 patients with diastematomyelia (34 males, 104 females) who were treated at our hospital from May 1978 to April 2010. A total of 106 patients had double dural tubes (type 1 diastematomyelia), and 32 patients had single dural tubes (type 2 diastematomyelia). Radiographs, CT myelography, and MRI showed characteristic kyphoscoliosis, widening of the interpedicle distance, and bony, cartilaginous, and fibrous septum. The incidences of symptoms including characteristic changes of the dorsal skin, neurological disorders, and congenital spinal or foot deformity were significantly higher in type 1 than in type 2. Surgery is more effective for patients with type 1 diastematomyelia; patients without surgery showed no improvement.

Resection of a primary sarcoma of the diaphysis of a long bone creates a large defect. The biological options for reconstruction include the use of a vascularised and non-vascularised fibular autograft.

The purpose of the present study was to compare these methods of reconstruction.

Between 1985 and 2007, 53 patients (26 male and 27 female) underwent biological reconstruction of a diaphyseal defect after resection of a primary sarcoma. Their mean age was 20.7 years (3.6 to 62.4). Of these, 26 (49 %) had a vascularised and 27 (51 %) a non-vascularised fibular autograft. Either method could have been used for any patient in the study. The mean follow-up was 52 months (12 to 259). Oncological, surgical and functional outcome were evaluated. Kaplan–Meier analysis was performed for graft survival with major complication as the end point.

At final follow-up, eight patients had died of disease. Primary union was achieved in 40 patients (75%); 22 (42%) with a vascularised fibular autograft and 18 (34%) a non-vascularised (p = 0.167). A total of 32 patients (60%) required revision surgery. Kaplan–Meier analysis revealed a mean survival without complication of 36 months (0.06 to 107.3, sd 9) for the vascularised group and 88 months (0.33 to 163.9, sd 16) for the non-vascularised group (p = 0.035).

Both groups seem to be reliable biological methods of reconstructing a diaphyseal bone defect. Vascularised autografts require more revisions mainly due to problems with wound healing in distal sites of tumour, such as the foot.

Cite this article: Bone Joint J 2014;96-B:1258–63.

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 purpose of this study was to assess the stability of a developmental pelvic reconstruction system which extends the concept of triangular osteosynthesis with fixation anterior to the lumbosacral pivot point. An unstable Tile type-C fracture, associated with a sacral transforaminal fracture, was created in synthetic pelves. The new concept was compared with three other constructs, including bilateral iliosacral screws, a tension band plate and a combined plate with screws. The pubic symphysis was plated in all cases. The pelvic ring was loaded to simulate single-stance posture in a cyclical manner until failure, defined as a displacement of 2 mm or 2°. The screws were the weakest construct, failing with a load of 50 N after 400 cycles, with maximal translation in the craniocaudal axis of 12 mm. A tension band plate resisted greater load but failure occurred at 100 N, with maximal rotational displacement around the mediolateral axis of 2.3°.

The combination of a plate and screws led to an improvement in stability at the 100 N load level, but rotational failure still occurred around the mediolateral axis. The pelvic reconstruction system was the most stable construct, with a maximal displacement of 2.1° of rotation around the mediolateral axis at a load of 500 N.

We present an illustrative case using a modification of the Gaines procedure for the surgical management of patients with spondyloptosis. It involves excision of the inferior half of the body of L5 anteriorly combined with posterior reduction and fusion.

Aims

A total of 30 patients with thoracolumbar/lumbar adolescent idiopathic scoliosis (AIS) treated between 1989 and 2000 with anterior correction and fusion surgery using dual-rod instrumentation were reviewed.

The purpose of this study was to evaluate the long-term outcome of adults with spina bifida cystica (SBC) who had been treated either operatively or non-operatively for scoliosis during childhood.

We reviewed 45 patients with a SBC scoliosis (Cobb angle ≥ 50º) who had been treated at one of two children’s hospitals between 1991 and 2007. Of these, 34 (75.6%) had been treated operatively and 11 (24.4%) non-operatively. After a mean follow-up of 14.1 years (standard deviation (sd) 4.3) clinical, radiological and health-related quality of life (HRQOL) outcomes were evaluated using the Spina Bifida Spine Questionnaire (SBSQ) and the 36-Item Short Form Health Survey (SF-36).

Although patients in the two groups were demographically similar, those who had undergone surgery had a larger mean Cobb angle (88.0º (sd 20.5; 50.0 to 122.0); versus 65.7º (sd 22.0; 51.0 to 115.0); p < 0.01) and a larger mean clavicle–rib intersection difference (12.3 mm; (sd 8.5; 1 to 37); versus 4.1 mm, (sd 5.9; 0 to 16); p = 0.01) than those treated non-operatively. Both groups were statistically similar at follow-up with respect to walking capacity, neurological motor level, sitting balance and health-related quality of life (HRQOL) outcomes.

Spinal fusion in SBC scoliosis corrects coronal deformity and stops progression of the curve but has no clear effect on HRQOL.

Cite this article: Bone Joint J 2014; 96-B:1244–51

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 main form of treatment of a chordoma of the mobile spine is total en bloc spondylectomy (TES), but the clinical results are not satisfactory. Stand-alone carbon ion radiotherapy (CIRT) for bone and soft-tissue sarcomas has recently been reported to have a high rate of local control with a low rate of local recurrence.

We report two patients who underwent TES after CIRT for treating a chordoma in the lumbar spine with good medium-term outcomes. At operation, there remained histological evidence of viable tumour cells in both cases. After the combination use of TES following CIRT, neither patient showed signs of recurrence at the follow-up examination. These two cases suggest that CIRT should be combined with total spondylectomy in the treatment of chordoma of the mobile spine.

Cite this article: Bone Joint J 2013;95-B:1392–5.

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.

The dismal outcome of tuberculosis of the spine in the pre-antibiotic era has improved significantly because of the use of potent antitubercular drugs, modern diagnostic aids and advances in surgical management. MRI allows the diagnosis of a tuberculous lesion, with a sensitivity of 100% and specificity of 88%, well before deformity develops. Neurological deficit and deformity are the worst complications of spinal tuberculosis. Patients treated conservatively show an increase in deformity of about 15°. In children, a kyphosis continues to increase with growth even after the lesion has healed. Tuberculosis of the spine is a medical disease which is not primarily treated surgically, but operation is required to prevent and treat the complications. Panvertebral lesions, therapeutically refractory disease, severe kyphosis, a developing neurological deficit, lack of improvement or deterioration are indications for surgery. Patients who present with a kyphosis of 60° or more, or one which is likely to progress, require anterior decompression, posterior shortening, posterior instrumented stabilisation and anterior and posterior bone grafting in the active stage of the disease. Late-onset paraplegia is best prevented rather than treated. The awareness and suspicion of an atypical presentation of spinal tuberculosis should be high in order to obtain a good outcome. Therapeutically refractory cases of tuberculosis of the spine are increasing in association with the presence of HIV and multidrug-resistant tuberculosis.