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

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

Somatosensory evoked potentials (SSEPs) measure the conduction pathways from the periphery to the brain and can demonstrate the site of neurological impairment in a variety of locomotor conditions. SSEPs were studied in 44 children (64 feet) with surgically corrected club feet. Four children had unreproducible responses, 18 showed abnormal recordings and 22 showed normal responses. In a further 31 feet (21 children) subjected to motor electrophysiological tests, 16 (52%) were abnormal. Overall, 44 of 95 feet (46%) showed abnormal SSEPs or motor electrophysiological tests. Neurological abnormality was related both to the severity of the deformity and the surgical outcome. It was seen in 38% of feet with grade-2 and in 53% of feet with grade-3 deformity. A fair surgical result was obtained in 36% of feet with a conduction deficit and in only 6% with no abnormality. These results suggest an association between neurological abnormality as demonstrated by SSEPs or motor electrophysiological studies and the severity of deformity in club foot and its response to surgical treatment

Over a two-year period, 265 Norwegian orthopaedic surgeons working at 71 institutions performed 63 484 operations under a tourniquet. Their replies to a questionnaire revealed that they mostly followed modern guidelines in their use of the tourniquet. Most felt that the tourniquet could be left on for two hours, and that it could be re-applied after 15 minutes. A total of 26 complications (one in 2442 operations) that might have been due to the tourniquet were reported, of which 15 were neurological. Three were in the upper limb (one in 6155 operations) and 12 in the lower limb (one in 3752 operations). Two were permanent (one in 31742 operations), but the remainder resolved within six months. One permanent and one transient complication occurred after tourniquet times of three hours. The incidence of tourniquet complications is still at least as high as that estimated in the 1970s

We reviewed 55 patients with mid-lumbar myelomeningocele (L3 and L4) first seen over a 17-year period from 1970 to 1986 and followed up for an average of ten years. We assessed a number of factors which might affect hip stability and ability to walk, recording the natural history of clinical and radiological hip deformity. Two-thirds of the hips had become dislocated or subluxed by the end of the first year of life, involving 86% of hips in patients with an L3 level and 45% of those with an L4 level. All the hips that developed instability secondary to muscle imbalance did so within the first year. The neurological level was the most significant determinant of walking ability: all patients with L4 neurological levels could walk but only one-third of those with L3 lesions could do so. Hip stability, intelligence quotient and fixed deformity did not influence walking ability

We reviewed 64 anterolateral decompressions performed on 63 patients with tuberculosis of the dorsal spine (D. 1. to L. 1. ). The mean age of the patients was 35 years (9 to 73) with no gender preponderance. All patients had severe paraplegia (two cases grade III, 61 cases grade IV). The mean number of vertebral bodies affected was 2.6; the mean pre-treatment kyphosis was 24.8° (7 to 84). An average of 2.9 ribs were removed in the course of 64 procedures. The mean time taken at surgery was 2.45 hours when two ribs were removed and 3.15 hours when three ribs were removed. Twelve patients (19%) showed signs of neurological recovery within seven days, 33 patients (52%) within one month and 12 patients (19%) after two months; but six patients (10%) showed no neurological recovery. Forty patients were followed up for more than two years. In 34 (85%) of these patients there was no significant change in the kyphotic deformity; two patients (5%) showed an increase of more than 20°

We describe a 63-year-old man who had xanthomatosis of the right tendo Achillis. He had undergone excision of the left tendo Achillis 17 years earlier without reconstruction for the same condition. The neurological history and examination were normal. Blood investigations showed hypercholestrolaemia, for which he was being treated with statins. He was referred with pain in the right tendo Achillis and problems with footwear. He was treated by excision of the right tendo Achillis, the xanthomatous nodules and the involved skin, followed by reconstruction with a cadaver bone-tendon graft. At follow-up eight months postoperatively, the scar had healed well. He walked without pain and could wear any type of shoe. Plain radiographs showed that the bone graft had healed. The American Orthopaedic Foot and Ankle Society hindfoot score was 95/100. The patient’s subjective evaluation of the result was very good

Thirty-three patients who had undergone anterior cervical fusion for degenerative disc disease were reviewed to determine the efficacy of the procedure. Only patients who were available for examination and who had undergone operation at least one year previously were included in the review. Nearly all had had arm pain and three-quarters neck pain. Diminished neck movement and neurological abnormalities in the arms had been frequent findings. Diagnosis from the clinical features and plain radiographs is described. Myelography was not used routinely and discography was not used at all. Indications for operation and surgical technique are described. Results show that pain in the neck and arm was relieved in a high proportion of cases and that the neurological abnormalities often recovered. It is concluded that this operation is safe and has a definite place in the relief of pain from cervical disc degeneration resistant to conservative treatment

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 evaluated 30 patients with cervical myelopathy before and after decompressive surgery and compared them with 42 healthy controls. All were asked to grip and release their fingers as rapidly as possible for 15 seconds. Films recorded with a digital camera were divided into three files of five seconds each. Three doctors independently counted the number of grip and release cycles in a blinded manner (N1 represents the number of cycles for the first five-second segment, N2 for the second and N3 for the third). N2 and N3 of the pre-operative group were significantly fewer than those of the control group, and the postoperative group’s results were significantly greater than those of the pre-operative group. In the control group, the numbers decreased significantly with each succeeding five-second interval (fatigue phenomenon). In the pre-operative myelopathy group there was no significant difference between N1 and N2 (freezing phenomenon). The 15-second test is shown to be reliable in the quantitative evaluation of cervical myelopathy. Although it requires a camera and animation files, it can detect small changes in neurological status because of its precise and objective nature

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

Recent clinical studies have suggested that a neurological lesion may be a cause of adolescent idiopathic scoliosis and animal experiments have implicated the posterior column pathway. We have tried to determine if differences in neurological response could be detected and measured clinically, and have compared the threshold of detection of vibratory sensation in 20 girls with adolescent idiopathic scoliosis with that in 20 clinically normal age-matched controls. A highly significant reduction of the threshold of detection of vibration was seen in the scoliotic group compared to the controls (p less than 0.001). Curve magnitude did not correlate with this threshold for either the upper (r = 0.172) or lower extremity (r = 0.126). Significant asymmetry between right- and left-sided thresholds to vibration was demonstrated in the scoliotic group. Our study supports the concept that an aberration in the function of the posterior column pathway of the cord may be of primary importance in the aetiology of idiopathic scoliosis. A clinically practical test to measure this function is presented

1. The antero-posterior or sagittal diameter of the cervical spine has been measured radiographically in fifty-one Japanese men who fell into three groups-twenty with normal cervical spines, eleven with spondylosis but no neurological symptoms, and twenty with spondylosis and myelopathy. 2. The average normal diameter was found smaller by 2·25 millimetres in Japanese men than in European adults examined by other authors. 3. The average initial diameter in cases of spondylosis without neurological symptoms was found to be greater than normal, which suggests that the increased space round the cord helps to avoid compression. 4. The average initial diameter in cases of spondylosis with myelopathy was found to be less than normal, which suggests that compression may be determined by moderate osteophyte formation or disc protrusion. 5. The risk of myelopathy would appear to be high when the average diameter is 12 millimetres or less. 6. The difficulty with such radiological measurements is that standard lateral films cannot always record the degree of encroachment by disc protrusion or by hypertrophy of the soft tissues

1. The pathology and pathogenesis of dislocations and fracture-dislocations of the cervical spine has been reviewed. 2. A method of treatment using skeletal traction and manipulation under relaxant general anaesthesia is described. Results of treatment are given for all patients admitted to the Centre with flexion-rotation dislocations of the cervical spine complicated by neurological lesions, between November 1961 and December 1968. 3. After reviewing the literature and considering the results obtained in seventy-six cases, we advocate a policy of conservative management with gentle manipulation of the cervical spine in selected cases, reduction being maintained thereafter by skeletal traction. We reserve operation for the few cases that demonstrate late instability or for those rarer cases in which manipulation fails and the patient has either an incomplete neurological lesion or a double skeletal injury. 4. The low incidence of late instability after adequate conservative treatment is stressed, and the danger of overdistraction of the cervical spine by heavy traction in patients with severe ligamentous damage is emphasised

We present a study of ten consecutive patients who underwent excision of thoracic or thoracolumbar hemivertebrae for either angular deformity in the coronal plane, or both coronal and sagittal deformity. Vertebral excision was carried out anteriorly alone in two patients. Seven patients had undergone previous posterior spinal fusion. Their mean age at surgery was 13.4 years (6 to 19). The mean follow-up was 78.5 months (20 to 180). The results were evaluated by radiological review of the preoperative, postoperative and most recent follow-up films. The mean preoperative coronal curve was 78.2° (30 to 115) and was corrected to 33.9° (7 to 58) postoperatively, a mean correction of 59%. Preoperative coronal decompensation of 35 mm was improved to 11 mm postoperatively. Seven patients had significant coronal decompensation preoperatively, which was corrected to a physiological range postoperatively. There were no major complications and no neurological damage. We have shown that resection of thoracic and thoracolumbar hemivertebrae can be performed safely, without undue risk of neurological compromise, in experienced hands

We performed posterior fixation with a Hartshill-Ransford contoured loop in 43 patients with instability at the craniocervical junction. No external bracing was used. Fifteen patients had congenital malformations, ten had tumours, seven had 'bone-softening' conditions (such as osteogenesis imperfecta), five had suffered complicated fractures, three had occipito-C1-C2 hypermobility due to lax ligaments and three had severe degenerative spondylosis with pseudotumours of the transverse ligament. Twenty-nine patients had transoral decompression of the cord before fixation. In most cases, cancellous bone grafts taken from the iliac crest were used to induce fusion; in nine very ill patients, no bone graft was used. In the whole series there was no instance of construct failure, broken wire or laminar fracture. The best results were achieved in patients with tumours or bone-softening conditions. No patient with normal neurology deteriorated after surgery but seven had worse neurological deficits after operation than before. Neck stiffness caused half the patients to change their lifestyle

Forty-eight patients with achondroplasia and 24 with hypochondroplasia have been reviewed in order to clarify the differences between the two disorders and establish the height, body proportions and other clinical and radiological variations within each group. Some of the "classical" findings in achondroplasia are not always present, and hypochondroplasia at its most severe is indistinguishable from achondroplasia at its least severe. The frequency of spinal stenosis and neurological complications was established in an unselected group of 27 achondroplastic and 12 hypochondroplastic patients aged 10 years and over. Only three of the former were free of symptoms but only three developed serious complications (11 per cent). Measurement of radiographs of the lumbar canal did not in general correlate well with the severity of spinal stenosis symptoms, but it was found that the ratio of interpedicular distances at the first and fourth lumbar vertebrae had some value. Neurological complications were rare in patients with simple narrowing of the spinal canal or with persistence of a thoracolumbar kyphos but when these occurred together there was a high risk of serious neurological involvement

Aims

Some patients presenting with hip pain and instability and underlying acetabular dysplasia (AD) do not experience resolution of symptoms after surgical management. Hip-spine syndrome is a possible underlying cause. We hypothesized that there is a higher frequency of radiological spine anomalies in patients with AD. We also assessed the relationship between radiological severity of AD and frequency of spine anomalies.