Aims

To examine the relationship of sex steroid hormones with osteopenia in a nationally representative sample of men in the USA.

Osteoradionecrosis is a rare but recognised complication of radiotherapy. Cases have been described in the cervical spine following treatment for head and neck malignancies up to 25 years after administration of radiotherapy. We present a rare case of osteoradionecrosis affecting the L5 and S1 vertebral bodies in a 58-year-old woman who presented with low back pain 25 years after undergoing a hysterectomy with adjuvant radiotherapy for cancer of the cervix.

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. Patients and Methods. Between 2012 and 2017, 12 171 patients with degenerative lumbar diseases underwent primary lumbar spine surgery. We investigated five categories of potential predictors: patient factors (sex, age, body mass index, and primary disease), surgical factors (surgical procedures, operative time, and estimated blood loss), types of DT (inaccessible for suturing/clipping and the presence of cauda equina/nerve root herniation), repair techniques (suturing, clipping, fibrin glue, polyethylene glycol (PEG) hydrogel, and polyglycolic acid sheet), and postoperative management (drainage duration). Postoperative complications were evaluated in terms of dural leak, prolonged bed rest, headache, nausea/vomiting, delayed wound healing, postoperative neurological deficit, surgical site infection (SSI), and reoperation for DT. We performed multivariable regression analyses to evaluate the predictors of postoperative complications associated with DT. Results. In total, 429/12 171 patients (3.5%) had a DT. Multivariable analysis revealed that PEG hydrogel significantly reduced the incidence of dural leak and prolonged bed rest, and that patients treated with sealants (fibrin glue and PEG hydrogel) significantly less frequently suffered from headache. A longer drainage duration significantly increased the incidence of headache, nausea/vomiting, and delayed wound healing. Headache and nausea/vomiting were significantly more prevalent in younger female patients. Postoperative neurological deficit and reoperation for DT significantly depended on the presence of cauda equina/nerve root herniation. A longer operative time was the sole independent risk factor for SSI and was also a risk factor for dural leak, prolonged bed rest, and nausea/vomiting. Conclusion. Sealants, particularly PEG hydrogel, may be useful in reducing symptoms related to cerebrospinal fluid leakage, whereas prolonged drainage may be unnecessary. Younger female patients should be carefully treated when DT occurs. Cite this article: Bone Joint J 2019;101-B:1115–1121

Wrong-level surgery is a unique pitfall in spinal surgery and is part of the wider field of wrong-site surgery. Wrong-site surgery affects both patients and surgeons and has received much media attention. We performed this systematic review to determine the incidence and prevalence of wrong-level procedures in spinal surgery and to identify effective prevention strategies. We retrieved 12 studies reporting the incidence or prevalence of wrong-site surgery and that provided information about prevention strategies. Of these, ten studies were performed on patients undergoing lumbar spine surgery and two on patients undergoing lumbar, thoracic or cervical spine procedures. A higher frequency of wrong-level surgery in lumbar procedures than in cervical procedures was found. Only one study assessed preventative strategies for wrong-site surgery, demonstrating that current site-verification protocols did not prevent about one-third of the cases. The current literature does not provide a definitive estimate of the occurrence of wrong-site spinal surgery, and there is no published evidence to support the effectiveness of site-verification protocols. Further prevention strategies need to be developed to reduce the risk of wrong-site surgery

We report seven cases of patients with seropositive rheumatoid arthritis in whom involvement of the thoracic and lumbar vertebrae occurred. Histological corroboration is presented in four. Pathological lesions comprised various combinations of paravertebral joint erosions, erosive discitis, anteroposterior and rotatory instability, major lumbar nerve root compression, and vertebral collapse. Specific radiological features are presented, enabling a distinction to be made between pure degenerative spondylosis and rheumatoid spondylitis. We submit that subcervical rheumatoid spondylitis is commoner than is generally believed, though less common than rheumatoid involvement of the cervical spine.

We performed a biomechanical study on human cadaver spines to determine the effect of three different interbody cage designs, with and without posterior instrumentation, on the three-dimensional flexibility of the spine. Six lumbar functional spinal units for each cage type were subjected to multidirectional flexibility testing in four different configurations: intact, with interbody cages from a posterior approach, with additional posterior instrumentation, and with cross-bracing. The tests involved the application of flexion and extension, bilateral axial rotation and bilateral lateral bending pure moments. The relative movements between the vertebrae were recorded by an optoelectronic camera system. We found no significant difference in the stabilising potential of the three cage designs. The cages used alone significantly decreased the intervertebral movement in flexion and lateral bending, but no stabilisation was achieved in either extension or axial rotation. For all types of cage, the greatest stabilisation in flexion and extension and lateral bending was achieved by the addition of posterior transpedicular instrumentation. The addition of cross-bracing to the posterior instrumentation had a stabilising effect on axial rotation. The bone density of the adjacent vertebral bodies was a significant factor for stabilisation in flexion and extension and in lateral bending

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.

1. A new operation of body-to-body intervertebral fusion by grafts introduced through a posterior approach is described. This is a preliminary report of early results, with follow-up to two years, which seems to be encouraging.

2. In spondylolisthesis, abnormal mobility of the loose posterior neural arch is believed in itself to cause nerve root pressure, and excision of the arch is an important part of the operation.

3. In the few cases where spinal fusion is needed after removal of a prolapsed intervertebral disc—and the proportion is now very low—posterior intervertebral fusion has proved very satisfactory.

Low lumbar pain with radiation into the leg is a common symptom pattern caused by a number of pathological processes. Isolated disc resorption is one such entity which can be readily identified and is amenable to surgical treatment. This study consisted of two groups of patients. Group I were 50 patients suffering from isolated disc resorption at L5--S1 with ill-defined low backache extending into the buttocks and down one or both legs, but not into the feet. Clinical signs of nerve root dysfunction were found in 16 per cent of patients. Radiographic changes with loss of disc height, facet over-riding and intrusion into the nerve root canal and intervertebral foramen were common and frequently associated with sclerosis of the vertebral end-plate. Group II were a series of 45 patients with isolated disc resorption independently reviewed an average of 45 months after surgical decompression of the S1 (98 per cent) or lower lumbar nerve roots. Based on objective grading by the clinician and subjective assessment by the patient complete success was achieved in 62 per cent of the patients and partial success in 24 per cent. Provided there is full appreciation of the pathological anatomy, strict diagnostic criteria and meticulous surgery, decompression of the nerve root canal is a useful surgical procedure in severely disabled patients suffering from isolated disc resorption.

Lumbar spondylolysis can heal with conservative treatment, but few attempts have been made to identify factors which may affect union of the defects in the pars. We have evaluated, retrospectively, the effects of prognostic variables on bony union of pars defects in 134 young patients less than 18 years of age with 239 defects of the pars who had been treated conservatively. All patients were evaluated by CT scans when first seen and more than six months later at follow-up.

The results showed that the spinal level and the stage of the defects were the predominant factors. The site of the defects in the pars, the presence or development of spondylolisthesis, the condition of the contralateral pars, the degree of lumbar lordosis and the degree of lumbar inclination all significantly affected union.

Aims

To report the development of the technique for minimally invasive lumbar decompression using robotic-assisted navigation.

Aims

To identify the incidence and risk factors for five-year same-site recurrent disc herniation (sRDH) after primary single-level lumbar discectomy. Secondary outcome was the incidence and risk factors for five-year sRDH reoperation.

We studied 135 lumbar discs from 27 spines removed post-mortem from subjects of an average age of 31.5 years. Defects of the annulus fibrosus were classified as peripheral, circumferential or radiating; the nucleus pulposus as normal, moderately or severely degenerate. Peripheral tears were more frequent in the anterior annulus, except in the L5-S1 disc. Circumferential tears were equally distributed between the anterior and the posterior annulus. Almost all the radiating tears were in the posterior annulus, and closely related to the presence of severe nuclear degeneration. Histology suggested that peripheral tears were due to trauma rather than biochemical degradation, and that they developed independently of nuclear degeneration. The association of peripheral annular lesions with low back pain is uncertain but our study suggests that they may have a role in the pathogenesis of discogenic pain.

In a prospective, consecutive study we determined the frequency of common symptoms and signs in 300 patients with lumbar nerve-root compression syndromes. We compared 100 patients with disc herniation (mean age 43 years), 100 with lataral spinal stenosis (41 years) and 100 with central spinal stenosis (65 years), using a standard protocol of common signs and symptoms. The diagnoses were established by one or more of myelography, CT, MRI and nerve-root block, and all were confirmed at operation. The preoperative duration of symptoms was significantly shorter in patients with disc herniation. Pain at rest, at night, and on coughing was as common in lateral stenosis as in disc herniation, but regular consumption of analgesics was more common in patients with disc herniation. Positive straight-leg-raising tests were more common in disc herniation than in lateral stenosis and were uncommon in central stenosis. Motor disturbances were seen most often in central spinal stenosis, especially patellar reflex changes. Sensory disturbances were most common in patients with complete disc herniation.

Direct measurements were made on 2,166 lumbar vertebrae of 433 adult negro and caucasoid skeletons. On statistical analysis, forty-five vertebrae in twenty-seven skeletons were found to be stenotic, the mid-sagittal diameter being the significantly reduced dimension. Whereas spinal stenosis syndromes are rare in South African negroes, the lumbar canal is marginally narrower in the negro. There is a uniformity of configuration and capacity of the lumbar spinal canal, which transcends race and sex. By a new method of determining the dorsal limit of the lumbar canal on lateral plain radiography, the overall average lower limit of normal of the mid-sagittal diameter is established at 15 millimetres, and of the transverse diameter 20 millimetres. Bony degenerative changes are more likely to cause neurological compression in the nerve root tunnel than in the spinal canal. The role of skeletal narrowing of the spinal canal as an exclusive cause of the spinal stenosis syndrome may have been exaggerated.

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).