This study aimed to evaluate rasterstereography of the spine as a diagnostic test for adolescent idiopathic soliosis (AIS), and to compare its results with those obtained using a scoliometer. Adolescents suspected of AIS and scheduled for radiographs were included. Rasterstereographic scoliosis angle (SA), maximal vertebral surface rotation (ROT), and angle of trunk rotation (ATR) with a scoliometer were evaluated. The area under the curve (AUC) from receiver operating characteristic (ROC) plots were used to describe the discriminative ability of the SA, ROT, and ATR for scoliosis, defined as a Cobb angle > 10°. Test characteristics (sensitivity and specificity) were reported for the best threshold identified using the Youden method. AUC of SA, ATR, and ROT were compared using the bootstrap test for two correlated ROC curves method.Aims
Methods
Degenerative cervical spondylosis (DCS) is a common musculoskeletal disease that encompasses a wide range of progressive degenerative changes and affects all components of the cervical spine. DCS imposes very large social and economic burdens. However, its genetic basis remains elusive. Predicted whole-blood and skeletal muscle gene expression and genome-wide association study (GWAS) data from a DCS database were integrated, and functional summary-based imputation (FUSION) software was used on the integrated data. A transcriptome-wide association study (TWAS) was conducted using FUSION software to assess the association between predicted gene expression and DCS risk. The TWAS-identified genes were verified via comparison with differentially expressed genes (DEGs) in DCS RNA expression profiles in the Gene Expression Omnibus (GEO) (Accession Number: GSE153761). The Functional Mapping and Annotation (FUMA) tool for genome-wide association studies and Meta tools were used for gene functional enrichment and annotation analysis.Aims
Methods
Aims. Idiopathic scoliosis is the most common spinal deformity in adolescents and children. The aetiology of the disease remains unknown. Previous studies have shown a lower bone mineral density in individuals with idiopathic scoliosis, which may contribute to the causation. The aim of the present study was to compare bone health in adolescents with idiopathic scoliosis with controls. Methods. We included 78 adolescents with idiopathic scoliosis (57 female patients) at a mean age of 13.7 years (8.5 to 19.6) and 52 age- and sex-matched healthy controls (39 female patients) at a mean age of 13.8 years (9.1 to 17.6). Mean skeletal age, estimated according to the Tanner-Whitehouse 3 system (TW3), was 13.4 years (7.4 to 17.8) for those with idiopathic scoliosis, and 13.1 years (7.4 to 16.5) for the controls. Mean Cobb angle for those with idiopathic scoliosis was 29° (SD 11°). All individuals were scanned with dual energy x-ray absorptiometry (DXA) and peripheral quantitative CT (pQCT) of the left radius and tibia to assess bone density. Statistical analyses were performed with independent-samples t-test, the Mann-Whitney U test, and the chi-squared test. Results. Compared with controls, adolescents with idiopathic scoliosis had mean lower DXA values in the left femoral neck (0.94 g/cm. 2. (SD 0.14) vs 1.00 g/cm. 2. (SD 0.15)), left total hip (0.94 g/cm. 2. (SD 0.14) vs 1.01 g/cm. 2. (SD 0.17)), L1 to L4 (0.99 g/cm. 2. (SD 0.15) vs 1.06 g/cm. 2. (SD 0.17)) and distal radius (0.35 g/cm. 2. (SD 0.07) vs 0.39 g/cm. 2. (SD 0.08; all p ≤ 0.024), but not in the mid-radius (0.72 g/cm. 2. vs 0.74 g/cm. 2. ; p = 0.198, independent t-test) and total body less
The aim of this study was to compare the clinical and radiological outcomes of patients with early-onset scoliosis (EOS), who had undergone spinal fusion after distraction-based spinal growth modulation using either traditional growing rods (TGRs) or magnetically controlled growing rods (MCGRs). We undertook a retrospective review of skeletally mature patients who had undergone fusion for an EOS, which had been previously treated using either TGRs or MCGRs. Measured outcomes included sequential coronal T1 to S1 height and major curve (Cobb) angle on plain radiographs and any complications requiring unplanned surgery before final fusion.Aims
Methods
Anchorage of pedicle screw rod instrumentation in the elderly spine with poor bone quality remains challenging. Our study aims to evaluate how the screw bone anchorage is affected by screw design, bone quality, loading conditions, and cementing techniques. Micro-finite element (µFE) models were created from micro-CT (μCT) scans of vertebrae implanted with two types of pedicle screws (L: Ennovate and R: S4). Simulations were conducted for a 10 mm radius region of interest (ROI) around each screw and for a full vertebra (FV) where different cementing scenarios were simulated around the screw tips. Stiffness was calculated in pull-out and anterior bending loads.Aims
Methods
To describe the clinical, radiological, and functional outcomes in patients with isolated congenital thoracolumbar kyphosis who were treated with three-column osteotomy by posterior-only approach. Hospital records of 27 patients with isolated congenital thoracolumbar kyphosis undergoing surgery at a single centre were retrospectively analyzed. All patients underwent deformity correction which involved a three-column osteotomy by single-stage posterior-only approach. Radiological parameters (local kyphosis angle (KA), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic tilt (PT), sacral slope (SS), C7 sagittal vertical axis (C7 SVA), T1 slope, and pelvic incidence minus lumbar lordosis (PI-LL)), functional scores, and clinical details of complications were recorded.Aims
Methods
Spinal deformity surgery carries the risk of neurological injury. Neurophysiological monitoring allows early identification of intraoperative cord injury which enables early intervention resulting in a better prognosis. Although multimodal monitoring is the ideal, resource constraints make surgeon-directed intraoperative transcranial motor evoked potential (TcMEP) monitoring a useful compromise. Our experience using surgeon-directed TcMEP is presented in terms of viability, safety, and efficacy. We carried out a retrospective review of a single surgeon’s prospectively maintained database of cases in which TcMEP monitoring had been used between 2010 and 2017. The upper limbs were used as the control. A true alert was recorded when there was a 50% or more loss of amplitude from the lower limbs with maintained upper limb signals. Patients with true alerts were identified and their case history analyzed.Aims
Methods
The aim of this study is to test the hypothesis that three grades of sagittal compensation for standing posture (normal, compensated, and decompensated) correlate with health-related quality of life measurements (HRQOL). A total of 50 healthy volunteers (normal), 100 patients with single-level lumbar degenerative spondylolisthesis (LDS), and 70 patients with adult to elderly spinal deformity (deformity) were enrolled. Following collection of demographic data and HRQOL measured by the Scoliosis Research Society-22r (SRS-22r), radiological measurement by the biplanar slot-scanning full body stereoradiography (EOS) system was performed simultaneously with force-plate measurements to obtain whole body sagittal alignment parameters. These parameters included the offset between the centre of the acoustic meatus and the gravity line (CAM-GL), saggital vertical axis (SVA), T1 pelvic angle (TPA), McGregor slope, C2-7 lordosis, thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), PI-LL, sacral slope (SS), pelvic tilt (PT), and knee flexion. Whole spine MRI examination was also performed. Cluster analysis of the SRS-22r scores in the pooled data was performed to classify the subjects into three groups according to the HRQOL, and alignment parameters were then compared among the three cluster groups.Aims
Methods
Spinal fusion remains the gold standard in the treatment of idiopathic scoliosis. However, anterior vertebral body tethering (AVBT) is gaining widespread interest, despite the limited data on its efficacy. The aim of our study was to determine the clinical efficacy of AVBT in skeletally immature patients with idiopathic scoliosis. All consecutive skeletally immature patients with idiopathic scoliosis treated with AVBT enrolled in a longitudinal, multicentre, prospective database between 2013 and 2016 were analyzed. All patients were treated by one of two surgeons working at two independent centres. Data were collected prospectively in a multicentre database and supplemented retrospectively where necessary. Patients with a minimum follow-up of two years were included in the analysis. Clinical success was set a priori as a major coronal Cobb angle of < 35° at the most recent follow-up.Aims
Methods
We aimed to establish the short- and long-term efficacy of corticosteroid injection for coccydynia, and to determine if betamethasone or triamcinolone has the best effect. During 2009 to 2016, we treated 277 patients with chronic coccydynia with either one 6 mg betamethasone or one 20 mg triamcinolone cortisone injection. A susequent injection was given to 62 (26%) of the patients. All were reviewed three to four months after injection, and 241 replied to a questionnaire a mean of 36 months (12 to 88) after the last injection. No pain at the early review was considered early success. When the patient had not been subsequently operated on, and indicated on the questionnaire that they were either well or much better, it was considered a long-term success.Aims
Methods
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
Intraoperative 3D navigation (ION) allows high accuracy to be achieved in spinal surgery, but poor workflow has prevented its widespread uptake. The technical demands on ION when used in patients with adolescent idiopathic scoliosis (AIS) are higher than for other more established indications. Lean principles have been applied to industry and to health care with good effects. While ensuring optimal accuracy of instrumentation and safety, the implementation of ION and its associated productivity was evaluated in this study for AIS surgery in order to enhance the workflow of this technique. The aim was to optimize the use of ION by the application of lean principles in AIS surgery. A total of 20 consecutive patients with AIS were treated with ION corrective spinal surgery. Both qualitative and quantitative analysis was performed with real-time modifications. Operating time, scan time, dose length product (measure of CT radiation exposure), use of fluoroscopy, the influence of the reference frame, blood loss, and neuromonitoring were assessed.Aims
Methods
Loss of motion following spine segment fusion results in increased strain in the adjacent motion segments. However, to date, studies on the biomechanics of the cervical spine have not assessed the role of coupled motions in the lumbar spine. Accordingly, we investigated the biomechanics of the cervical spine following cervical fusion and lumbar fusion during simulated whiplash using a whole-human finite element (FE) model to simulate coupled motions of the spine. A previously validated FE model of the human body in the driver-occupant position was used to investigate cervical hyperextension injury. The cervical spine was subjected to simulated whiplash exposure in accordance with Euro NCAP (the European New Car Assessment Programme) testing using the whole human FE model. The coupled motions between the cervical spine and lumbar spine were assessed by evaluating the biomechanical effects of simulated cervical fusion and lumbar fusion.Objectives
Methods
The aim of this study was to compare the peak pull-out force
(PPF) of pedicle-lengthening screws (PLS) and traditional pedicle
screws (TPS) using instant and cyclic fatigue testing. A total of 60 lumbar vertebrae were divided into six groups:
PLS submitted to instant pull-out and fatigue-resistance testing
(groups A1 and A2, respectively), TPS submitted to instant pull-out
and fatigue-resistance testing (groups B1 and B2, respectively)
and PLS augmented with 2 ml polymethylmethacrylate, submitted to
instant pull-out and fatigue-resistance testing (groups C1 and C2,
respectively). The PPF and normalized PPF (PPFn) for bone mineral density
(BMD) were compared within and between all groups.Aims
Materials and Methods
We report a series of 15 children, six male and nine female, of average age 20 months, seen at a paediatric orthopaedic clinic with torticollis. Orthopaedic examination revealed a normal range of neck movement in all cases but in seven there was palpable tightness in the absence of true shortening or contracture of the sternomastoid muscle. The patients were prospectively referred for ocular examination. In five of the 15 an ocular cause for the torticollis was detected with underaction of the superior oblique muscle in three, paresis of the lateral rectus muscle in one and nystagmus in one. Another two patients were found to have an abnormal ocular examination which was thought to be unrelated to their torticollis. Three of the patients with ocular torticollis required extra-ocular muscle surgery to abolish the
We aimed to retrospectively assess the accuracy and safety of
CT navigated pedicle screws and to compare accuracy in the cervical
and thoracic spine (C2-T8) with (COMB) and without (POST) prior
anterior surgery (anterior cervical discectomy or corpectomy and
fusion with ventral plating: ACDF/ACCF). A total of 592 pedicle screws, which were used in 107 consecutively
operated patients (210 COMB, 382 POST), were analysed. The accuracy
of positioning was determined according to the classification of
Gertzbein and Robbins on post-operative CT scans.Aims
Patients and Methods
The aim of this study was to determine if positive Waddell signs
were related to patients’ demographics or to perception of their
quality of life. This prospective cross-sectional study included 479 adult patients
with back pain from a university spine centre. Each completed SF-12
and Oswestry Disability Index (ODI) questionnaires and underwent
standard spinal examinations to elicit Waddell signs. The relationship
between Waddell signs and age, gender, ODI, Mental Component Score
(MCS), and Physical Component Score (PCS) scores was determined.Aims
Patients and Methods
The objective of this study was to assess the association between whole body sagittal balance and risk of falls in elderly patients who have sought treatment for back pain. Balanced spinal sagittal alignment is known to be important for the prevention of falls. However, spinal sagittal imbalance can be markedly compensated by the lower extremities, and whole body sagittal balance including the lower extremities should be assessed to evaluate actual imbalances related to falls. Patients over 70 years old who visited an outpatient clinic for back pain treatment and underwent a standing whole-body radiograph were enrolled. Falls were prospectively assessed for 12 months using a monthly fall diary, and patients were divided into fallers and non-fallers according to the history of falls. Radiological parameters from whole-body radiographs and clinical data were compared between the two groups.Objectives
Methods
Cervical spondylosis is often accompanied by dizziness. It has
recently been shown that the ingrowth of Ruffini corpuscles into
diseased cervical discs may be related to cervicogenic dizziness.
In order to evaluate whether cervicogenic dizziness stems from the
diseased cervical disc, we performed a prospective cohort study
to assess the effectiveness of anterior cervical discectomy and
fusion on the relief of dizziness. Of 145 patients with cervical spondylosis and dizziness, 116
underwent anterior cervical decompression and fusion and 29 underwent
conservative treatment. All were followed up for one year. The primary
outcomes were measures of the intensity and frequency of dizziness.
Secondary outcomes were changes in the modified Japanese Orthopaedic
Association (mJOA) score and a visual analogue scale score for neck
pain.Aims
Patients and Methods
The aim of this study was to report a retrospective, consecutive
series of patients with adolescent idiopathic scoliosis (AIS) who
were treated with posterior minimally invasive surgery (MIS) with
a mean follow-up of two years ( We prospectively collected the data of 70 consecutive patients
with AIS treated with MIS using three incisions and a muscle-splitting
approach by a single surgeon between June 2013 and February 2016
and these were retrospectively reviewed. There were eight male and
62 female patients with a mean age of 15 years (Aims
Patients and Methods
Loosening of pedicle screws is a major complication of posterior
spinal stabilisation, especially in the osteoporotic spine. Our
aim was to evaluate the effect of cement augmentation compared with
extended dorsal instrumentation on the stability of posterior spinal
fixation. A total of 12 osteoporotic human cadaveric spines (T11-L3) were
randomised by bone mineral density into two groups and instrumented
with pedicle screws: group I (SHORT) separated T12 or L2 and group
II (EXTENDED) specimen consisting of T11/12 to L2/3. Screws were
augmented with cement unilaterally in each vertebra. Fatigue testing
was performed using a cranial-caudal sinusoidal, cyclic (1.0 Hz)
load with stepwise increasing peak force.Aims
Materials and Methods
The aims of our study were to provide long-term information on
the behaviour of the thoracolumbar/lumbar (TL/L) curve after thoracic
anterior correction and fusion (ASF) and to determine the impact
of ASF on pulmonary function. A total of 41 patients (four males, 37 females) with main thoracic
(MT) adolescent idiopathic scoliosis (AIS) treated with ASF were
included. Mean age at surgery was 15.2 years (11 to 27). Mean follow-up
period was 13.5 years (10 to 18).Aims
Patients and Methods
Percutaneous placement of pedicle screws is a
well-established technique, however, no studies have compared percutaneous
and open placement of screws in the thoracic spine. The aim of this
cadaveric study was to compare the accuracy and safety of these
techniques at the thoracic spinal level. A total of 288 screws were
inserted in 16 (eight cadavers, 144 screws in percutaneous and eight
cadavers, 144 screws in open). Pedicle perforations and fractures
were documented subsequent to wide laminectomy followed by skeletalisation
of the vertebrae. The perforations were classified as grade 0: no
perforation, grade 1: <
2 mm perforation, grade 2: 2 mm to 4
mm perforation and grade 3: >
4 mm perforation. In the percutaneous
group, the perforation rate was 11.1% with 15 (10.4%) grade 1 and
one (0.7%) grade 2 perforations. In the open group, the perforation
rate was 8.3% (12 screws) and all were grade 1. This difference
was not significant (p = 0.45). There were 19 (13.2%) pedicle fractures
in the percutaneous group and 21 (14.6%) in the open group (p =
0.73). In summary, the safety of percutaneous fluoroscopy-guided
pedicle screw placement in the thoracic spine between T4 and T12
is similar to that of the conventional open technique. Cite this article:
Whiplash injury is surrounded by controversy in both the medical and legal world. The debate on whether it is either a potentially serious medical condition or a social problem is ongoing. This paper briefly examines a selection of studies on low velocity whiplash injury (LVWI) and whiplash associated disorder (WAD) and touches upon the pathophysiological and epidemiological considerations, cultural and geographical differences and the effect of litigation on chronicity. The study concludes that the evidence for significant physical injury after LVWI is poor, and if significant disability is present after such injury, it will have to be explained in terms of psychosocial factors.
The aim of this study was to evaluate the feasibility
of using the intact S1 nerve root as a donor nerve to repair an avulsion
of the contralateral lumbosacral plexus. Two cohorts of patients
were recruited. In cohort 1, the L4–S4 nerve roots of 15 patients
with a unilateral fracture of the sacrum and sacral nerve injury
were stimulated during surgery to establish the precise functional
distribution of the S1 nerve root and its proportional contribution
to individual muscles. In cohort 2, the contralateral uninjured
S1 nerve root of six patients with a unilateral lumbosacral plexus
avulsion was transected extradurally and used with a 25 cm segment
of the common peroneal nerve from the injured leg to reconstruct
the avulsed plexus. The results from cohort 1 showed that the innervation of S1 in
each muscle can be compensated for by L4, L5, S2 and S3. Numbness
in the toes and a reduction in strength were found after surgery
in cohort 2, but these symptoms gradually disappeared and strength
recovered. The results of electrophysiological studies of the donor
limb were generally normal. Severing the S1 nerve root does not appear to damage the healthy
limb as far as clinical assessment and electrophysiological testing
can determine. Consequently, the S1 nerve can be considered to be
a suitable donor nerve for reconstruction of an avulsed contralateral
lumbosacral plexus. Cite this article:
Acute angulation at the thoracolumbar junction
with segmental subluxation of the spine occurring at the level above
an anteriorly hypoplastic vertebra in otherwise normal children
is a rare condition described as infantile developmental thoracolumbar
kyphosis. Three patient series with total of 18 children have been
reported in the literature. We report five children who presented
with thoracolumbar kyphosis and discuss the treatment algorithm. We
reviewed the medical records and spinal imaging at initial clinical
presentation and at minimum two-year follow-up. The mean age at
presentation was eight months (two to 12). All five children had
L2 anterior vertebral body hypoplasia. The kyphosis improved spontaneously
in three children kept under monitoring. In contrast, the deformity
was progressive in two patients who were treated with bracing. The
kyphosis and segmental subluxation corrected at latest follow-up
(mean age 52 months; 48 to 60) in all patients with near complete
reconstitution of the anomalous vertebra. The deformity and radiological
imaging on a young child can cause anxiety to both parents and treating
physicians. Diagnostic workup and treatment algorithm in the management
of infantile developmental thoracolumbar kyphosis is proposed. Observation
is indicated for non-progressive kyphosis and bracing if there is evidence
of kyphosis and segmental subluxation deterioration beyond walking
age. Surgical stabilisation of the spine can be reserved for severe
progressive deformities unresponsive to conservative treatment. Cite this article:
We describe 13 patients with cerebral palsy and
lordoscoliosis/hyperlordosis of the lumbar spine who underwent a posterior
spinal fusion at a mean age of 14.5 years (10.8 to 17.4) to improve
sitting posture and relieve pain. The mean follow-up was 3.3 years
(2.2 to 6.2). The mean pre-operative lumbar lordosis was 108° (80
to 150°) and was corrected to 62° (43° to
85°); the mean thoracic kyphosis from 17° (-23° to
35°) to 47° (25° to 65°);
the mean scoliosis from 82° (0° to 125°)
to 22° (0° to 40°); the mean pelvic
obliquity from 21° (0° to 38°)
to 3° (0° to 15°); the mean sacral
slope from 79° (54° to 90°) to
50° (31° to 66°). The mean pre-operative
coronal imbalance was 5 cm (0 cm to 8.9 cm) and was corrected to
0.6 cm (0 to 3.2). The mean sagittal imbalance of -8 cm (-16 cm
to 7.8 cm) was corrected to -1.6 cm
(-4 cm to 2.5 cm). The mean operating time was 250 minutes (180
to 360 minutes) and intra-operative blood loss 0.8 of estimated
blood volume (0.3 to 2 estimated blood volume). The mean intensive
care and hospital stay were 3.5 days (2 to 8) and 14.5 days (10
to 27), respectively. Three patients lost a significant amount of
blood intra-operatively and subsequently developed chest or urinary
infections and superior mesenteric artery syndrome. An increased pre-operative lumbar lordosis and sacral slope were
associated with increased peri-operative morbidity: scoliosis and
pelvic obliquity were not. A reduced lumbar lordosis and increased
thoracic kyphosis correlated with better global sagittal balance
at follow-up. All patients and their parents reported excellent
surgical outcomes. Lordoscoliosis and hyperlordosis are associated with significant
morbidity in quadriplegic patients. They are rare deformities and
their treatment is challenging. Sagittal imbalance is the major
component: it can be corrected by posterior fusion of the spine
with excellent functional results. Cite this article:
The purpose of this study was to evaluate and
compare the effect of short segment pedicle screw instrumentation and
an intermediate screw (SSPI+IS) on the radiological outcome of type
A thoracolumbar fractures, as judged by the load-sharing classification,
percentage canal area reduction and remodelling. We retrospectively evaluated 39 patients who had undergone hyperlordotic
SSPI+IS for an AO-Magerl Type-A thoracolumbar fracture. Their mean
age was 35.1 (16 to 60) and the mean follow-up was 22.9 months (12
to 36). There were 26 men and 13 women in the study group. In total,
18 patients had a load-sharing classification score of seven and
21 a score of six. All radiographs and CT scans were evaluated for
sagittal index, anterior body height compression (%ABC), spinal
canal area and encroachment. There were no significant differences
between the low and high score groups with respect to age, duration
of follow-up, pre-operative sagittal index or pre-operative anterior
body height compression (p = 0.217, 0.104, 0.104, and 0.109 respectively).
The mean pre-operative sagittal index was 19.6° (12° to 28°) which
was corrected to -1.8° (-5° to 3°) post-operatively and 2.4° (0°
to 8°) at final follow-up (p = 0.835 for sagittal deformity). No
patient needed revision for loss of correction or failure of instrumentation. Hyperlordotic reduction and short segment pedicle screw instrumentation
and an intermediate screw is a safe and effective method of treating
burst fractures of the thoracolumbar spine. It gives excellent radiological
results with a very low rate of failure regardless of whether the
fractures have a high or low load-sharing classification score. Cite this article
To evaluate the neck strength of school-aged rugby players, and
to define the relationship with proxy physical measures with a view
to predicting neck strength. Cross-sectional cohort study involving 382 rugby playing schoolchildren
at three Scottish schools (all male, aged between 12 and 18 years).
Outcome measures included maximal isometric neck extension, weight,
height, grip strength, cervical range of movement and neck circumference.Objectives
Methods
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:
There are many causes of paraspinal muscle weakness which give rise to the dropped-head syndrome. In the upper cervical spine the central portion of the spinal cord innervates the cervical paraspinal muscles. Dropped-head syndrome resulting from injury to the central spinal cord at this level has not previously been described. We report two patients who were treated acutely for this condition. Both presented with weakness in the upper limbs and paraspinal cervical musculature after a fracture of C2. Despite improvement in the strength of the upper limbs, the paraspinal muscle weakness persisted in both patients. One ultimately underwent cervicothoracic fusion to treat her dropped-head syndrome. While the cause of the dropped-head syndrome cannot be definitively ascribed to the injuries to the spinal cord, this pattern is consistent with the known patho-anatomical mechanisms of both injury to the central spinal cord and dropped-head syndrome.
This study prospectively compared the efficacy of kyphoplasty using a Jack vertebral dilator and balloon kyphoplasty to treat osteoporotic compression fractures between T10 and L5. Between 2004 and 2009, two groups of 55 patients each underwent vertebral dilator kyphoplasty and balloon kyphoplasty, respectively. Pain, function, the Cobb angle, and the anterior and middle height of the vertebral body were assessed before and after operation. Leakage of bone cement was recorded. The post-operative change in the Cobb angle was significantly greater in the dilator kyphoplasty group than in the balloon kyphoplasty group (−9.51° ( These findings suggest that vertebral dilator kyphoplasty can facilitate better correction of kyphotic deformity and may ultimately be a safer procedure in reducing leakage of bone cement.
Ventral screw osteosynthesis is a common surgical
method for treating fractures of the odontoid peg, but there is still
no consensus about the number and diameter of the screws to be used.
The purpose of this study was to develop a more accurate measurement
technique for the morphometry of the odontoid peg (dens axis) and
to provide a recommendation for ventral screw osteosynthesis. Images of the cervical spine of 44 Caucasian patients, taken
with a 64-line CT scanner, were evaluated using the measuring software
MIMICS. All measurements were performed by two independent observers.
Intraclass correlation coefficients were used to measure inter-rater
variability. The mean length of the odontoid peg was 39.76 mm ( The cross-section of the odontoid peg is not circular but slightly
elliptical, with a 10% greater diameter in the sagittal plane. In
the majority of cases (70.5%) the odontoid peg offers enough room
for two 3.5 mm cannulated cortical screws. Cite this article:
We reviewed 212 consecutive patients with adolescent
idiopathic scoliosis who underwent posterior spinal arthrodesis
using all pedicle screw instrumentation in terms of clinical, radiological
and Scoliosis Research Society (SRS)-22 outcomes. In Group 1 (51
patients), the correction was performed over two rods using bilateral
segmental pedicle screws. In Group 2 (161 patients), the correction
was performed over one rod using unilateral segmental pedicle screws
with the second rod providing stability of the construct
through two-level screw fixation at proximal and distal ends. The
mean age at surgery was
14.8 years in both groups. Comparison between groups showed no significant
differences with regard to age and Risser grade at surgery, pre-
and post-operative scoliosis angle, coronal Cobb correction, length
of hospital stay and SRS scores. Correction of upper thoracic curves
was significantly better in Group 1 (p = 0.02). Increased surgical time
and intra-operative blood loss was recorded in Group 1 (p <
0.001
and p = 0.04, respectively). The implant cost was reduced by mean
35% in Group 2 due to the lesser number of pedicle screws. Unilateral and bilateral pedicle screw techniques have both achieved
excellent deformity correction in adolescent patients with idiopathic
scoliosis, which was maintained at two-year follow-up. This has
been associated with high patient satisfaction and low complication
rates.
We report the results of vertebral column resection
(VCR) for paediatric patients with spinal deformity. A total of
49 VCRs in paediatric patients from four university hospitals between
2005 and 2009 with a minimum two-year follow-up were retrospectively
identified. After excluding single hemivertebral resections (n =
25) and VCRs performed for patients with myelomeningocele (n = 6),
as well as spondylectomies performed for tumour (n = 4), there were
14 patients who had undergone full VCR at a mean age of 12.3 years
(6.5 to 17.9). The aetiology was congenital scoliosis in five, neuromuscular
scoliosis in three, congenital kyphosis in two, global kyphosis
in two, adolescent idiopathic scoliosis in one and secondary scoliosis
in one. A total of seven anteroposterior and seven posterolateral approaches
were used. The mean major curve deformity was 86° (67° to 120°) pre-operatively
and 37° (17° to 80°) at the two-year follow-up; correction was a
mean of 54% (18% to 86%) in the anteroposterior and 60% (41% to
70%) in the posterolateral group at the two-year follow-up (p =
0.53). The mean Scoliosis Research Society-24 total scores were
100 (92 to 108) for the anteroposterior and 102 (95 to 105) for
the posterolateral group. There was one paraparesis in the anteroposterior
group necessitating urgent re-decompression, with a full recovery. Patients undergoing VCR are highly satisfied after a successful
procedure.
We reviewed the outcome of a retrospective case series of eight patients with atlantoaxial instability who had been treated by percutaneous anterior transarticular screw fixation and grafting under image-intensifier guidance between December 2005 and June 2008. The mean follow-up was 19 months (8 to 27). All eight patients had a solid C1–2 fusion. There were no breakages or displacement of screws. All the patients with pre-operative neck pain had immediate relief from their symptoms or considerable improvement. There were no major complications. Our preliminary clinical results suggest that percutaneous anterior transarticulation screw fixation is technically feasible, safe, useful and minimally invasive when using the appropriate instruments allied to intra-operative image intensification, and by selecting the correct puncture point, angle and depth of insertion.
This study assessed the frequency of acute injury to the spinal cord in Irish Rugby over a period of ten years, between 1995 and 2004. There were 12 such injuries; 11 were cervical and one was thoracic. Ten occurred in adults and two in schoolboys. All were males playing Rugby Union and the mean age at injury was 21.6 years (16 to 36). The most common mechanism of injury was hyperflexion of the cervical spine and the players injured most frequently were playing at full back, hooker or on the wing. Most injuries were sustained during the tackle phase of play. Six players felt their injury was preventable. Eight are permanently disabled as a result of their injury.
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
In patients with osteoporosis there is always
a strong possibility that pedicle screws will loosen. This makes
it difficult to select the appropriate osteoporotic patient for
a spinal fusion. The purpose of this study was to determine the
correlation between bone mineral density (BMD) and the magnitude
of torque required to insert a pedicle screw. To accomplish this,
181 patients with degenerative disease of the lumbar spine were
studied prospectively. Each underwent dual-energy x-ray absorptiometry
(DEXA) and intra-operative measurement of the torque required to
insert each pedicle screw. The levels of torque generated in patients
with osteoporosis and osteopenia were significantly lower than those
achieved in normal patients. Positive correlations were observed between
BMD and T-value at the instrumented lumbar vertebrae, mean BMD and
mean T-value of the lumbar vertebrae, and mean BMD and mean T-value
of the proximal femur. The predictive torque (Nm) generated during pedicle
screw insertion was [-0.127 + 1.62 × (BMD at the corresponding lumbar
vertebrae)], as measured by linear regression analysis. The positive
correlation between BMD and the maximum torque required to insert
a pedicle screw suggests that pre-operative assessment of BMD may
be useful in determining the ultimate strength of fixation of a
device, as well as the number of levels that need to be fixed with
pedicle screws in patients who are suspected of having osteoporosis.
Thoracic back pain caused by osteoarthritis of a single costovertebral joint is a poorly recognised condition. We report a series of five patients who were successfully treated by resection arthroplasty of this joint. Each had received a preliminary image-guided injection of local anaesthetic and steroid into the joint to confirm it as the source of pain. The surgical technique is described. There were no complications. The pain improved from a mean of 7.0 (6 to 8) on a visual analogue scale to 2.0 (0 to 4) post-operatively. The final post-operative Oswestry disability index was a mean of 19.4 (9 to 38). Isolated osteoarthritis of a costovertebral joint is a rare but treatable cause of thoracic back pain. It is possible to obtain excellent short- and intermediate-term relief from pain with resection arthroplasty in appropriately selected patients.
The purpose of this study was to evaluate whether concerns about the release of metal ions in metal-on-metal total hip replacements (THR) should be extended to patients with metal-bearing total disc replacements (TDR). Cobalt and chromium levels in whole blood and serum were measured in ten patients with a single-level TDR after a mean follow-up of 34.5 months (13 to 61) using inductively-coupled plasma mass spectrometry. These metal ion levels were compared with pre-operative control levels in 81 patients and with metal ion levels 12 months after metal-on-metal THR (n = 21) and resurfacing hip replacement (n = 36). Flexion-extension radiographs were used to verify movement of the TDR. Cobalt levels in whole blood and serum were significantly lower in the TDR group than in either the THR (p = 0.007) or the resurfacing group (p <
0.001). Both chromium levels were also significantly lower after TDR These results suggest that there is minimal cause for concern about high metal ion concentrations after TDR, as the levels appear to be only moderately elevated. However, spinal surgeons using a metal-on-metal TDR should still be aware of concerns expressed in the hip replacement literature about toxicity from elevated metal ion levels, and inform their patients appropriately.
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.
We reviewed 75 patients (57 men and 18 women), who had undergone tension-band laminoplasty for cervical spondylotic myelopathy (42 patients) or compression myelopathy due to ossification of the posterior longitudinal ligament (33 patients) and had been followed for more than ten years. Clinical and functional results were estimated using the Japanese Orthopaedic Association score. The rate of recovery and the level of postoperative axial neck pain were also recorded. The pre- and post-operative alignment of the cervical spine (Ishihara curve index indicating lordosis of the cervical spine) and the range of movement (ROM) of the cervical spine were also measured. The mean rate of recovery of the Japanese Orthopaedic Association score at final follow-up was 52.1% (
Segmental vessel ligation during anterior spinal surgery has been associated with paraplegia. However, the incidence and risk factors for this devastating complication are debated. We reviewed 346 consecutive paediatric and adolescent patients ranging in age from three to 18 years who underwent surgery for anterior spinal deformity through a thoracic or thoracoabdominal approach, during which 2651 segmental vessels were ligated. There were 173 patients with idiopathic scoliosis, 80 with congenital scoliosis or kyphosis, 43 with neuromuscular and 31 with syndromic scoliosis, 12 with a scoliosis associated with intraspinal abnormalities, and seven with a kyphosis. There was only one neurological complication, which occurred in a patient with a 127° congenital thoracic scoliosis due to a unilateral unsegmented bar with contralateral hemivertebrae at the same level associated with a thoracic diastematomyelia and tethered cord. This patient was operated upon early in the series, when intra-operative spinal cord monitoring was not available. Intra-operative spinal cord monitoring with the use of somatosensory evoked potentials alone or with motor evoked potentials was performed in 331 patients. This showed no evidence of signal change after ligation of the segmental vessels. In our experience, unilateral segmental vessel ligation carries no risk of neurological damage to the spinal cord unless performed in patients with complex congenital spinal deformities occurring primarily in the thoracic spine and associated with intraspinal anomalies at the same level, where the vascular supply to the cord may be abnormal.
This prospective study of 136 children with progressive infantile scoliosis treated under the age of four years, and followed up for nine years, shows that the scoliosis can be reversed by harnessing the vigorous growth of the infant to early treatment by serial corrective plaster jackets. In 94 children (group 1), who were referred and treated in the early stages of progression, at a mean age of one year seven months (6 to 48 months) and with a mean Cobb angle of 32° (11° to 65°), the scoliosis resolved by a mean age of three years and six months. They needed no further treatment and went on to lead a normal life. At the last follow-up, their mean age was 11 years and two months (1 year 10 months to 25 years 2 months), 23 (24.5%) were at Risser stages 4 and 5 and 13 girls were post-menarchal. In 42 children (group 2), who were referred late at a mean age of two years and six months (11 to 48 months) and with a mean Cobb angle of 52° (23° to 92°), treatment could only reduce but not reverse the deformity. At the last follow-up, at a mean age of ten years and four months (1 year 9 months to 22 years 1 month), eight children (19%) were at Risser stages 4 and 5 and five girls were post-menarchal. Fifteen children (35.7%) had undergone spinal fusion, as may all the rest eventually.
Traumatic atlanto-occipital dislocation in adults is usually fatal and survival without neurological deficit is rare. The surgical management of those who do survive is difficult and controversial. Most authorities recommend posterior occipitoaxial fusion, but this compromises cervical rotation. We describe a case in which a patient with a traumatic atlanto-occipital disruption but no neurological deficit was treated by atlanto-occipital fusion using a new technique consisting of cancellous bone autografting supported by an occipital plate linked by rods to lateral mass screws in the atlas. The technique is described in detail. At one year the neck was stable, radiological fusion had been achieved, and atlantoaxial rotation preserved. The rationale behind this approach is discussed and the relevant literature reviewed. We recommend the technique for injuries of this type.
The scoliosis observed in chickens after pinealectomy resembles that seen in humans with an adolescent idiopathic scoliosis, suggesting that melatonin deficiency may be responsible. However, to date there have been no studies of pineal gland glucose metabolism in patients with adolescent idiopathic scoliosis that might support this hypothesis. We examined the excretion of urinary 6-sulfatoxyl-melatonin as well as the glucose metabolism of the pineal gland in 14 patients with an adolescent idiopathic scoliosis and compared them with those of 13 gender-matched healthy controls using F-18 fluorodeoxyglucose brain positron emission tomography. There was no significant difference in the level of urinary 6-sulfatoxyl-melatonin or pineal gland metabolism between the study and the control group. We conclude that permanent melatonin deficiency is not a causative factor in the aetiology of adolescent idiopathic scoliosis.