1. Five cases of scoliosis with paraplegia are reported, and thirty-six comparable cases from the literature are reviewed. These forty-one cases have been studied with the object of determining the etiology of scoliosis, the reason why cord compression sometimes develops, and the results of conservative and operative treatment of such compression of the cord. 2. The cause of paraplegia is nearly always compression of the spinal cord by the dura, which, in severe scoliosis, is under longitudinal tension because of its firm attachment to the foramen magnum above and the sacrum below. Such tension, resisting displacement of the spinal cord from the straight line, may be shown to cause incomplete spinal block even when there is no paralysis. 3. When paralysis occurs it usually develops during the years of most rapid growth, the tight dura being unable to accommodate itself to the rate of growth of the spinal column; cord compression is probably increased by narrowing of the dural sac by rotational displacement. 4. The most striking results have been secured by laminectomy with section of the dura and sometimes division of dentate ligaments and tight nerve roots. After such division there is evidence of release of compression: the cord herniates through the dural slit; and spinal pulsation returns. 5. It is important to control bleeding in order to avoid post-operative compression by blood clot; and to prevent leakage of cerebro-spinal fluid through the arachnoid. 6. It is unwise to perform spinal fusion at the same time as decompression because it increases the danger of haematoma formation. Moreover the improvement gained by decompression is maintained even if no fusion of the spine is performed. 7. Conservative treatment of scoliosis with paraplegia should not be continued for long periods unless there is evidence of early and progressive improvement because prolonged compression causes irreversible changes in the cord. 8. In three cases, paraplegia was not due to dural compression: one turned out later to be a case of syringomyelia; one, reported by Heyman, was due to the pressure of a bone spur; and one, reported in this series, was due to a congenital tight band of developmental origin which might have caused the scoliosis as well as the paralysis, and in which, after resection of the band, recovery from the paralysis was complete

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

1. A comparison of the results of sixty patients with Pott's paraplegia, half operated upon and half treated conservatively, showed that better results were achieved in a much shorter time in those treated surgically. 2. Extra-pleural antero-lateral decompression is the operation of choice in cases of Pott's paraplegia. 3. The operation should be done as soon as the general condition of the patient allows, and should not be left until the disease is quiescent. 4. The greatest improvement is found in those patients who are still ambulant. 5. Although the gain in patients with complete paraplegia may be small, relief from painful flexor spasms and the healing of bed-sores often justify surgical treatment. 6. Fusion of the vertebral bodies can be carried out at the same sitting using healthy ribs and sometimes cancellous bone, with satisfactory results

Aims. To address the natural history of severe post-tuberculous (TB) kyphosis, with focus upon the long-term neurological outcome, occurrence of restrictive lung disease, and the effect on life expectancy. . Patients and Methods. This is a retrospective clinical review of prospectively collected imaging data based at a single institute. A total of 24 patients of Southern Chinese origin who presented with spinal TB with a mean of 113° of kyphosis (65° to 159°) who fulfilled inclusion criteria were reviewed. Plain radiographs were used to assess the degree of spinal deformity. Myelography, CT and MRI were used when available to assess the integrity of the spinal cord and canal. Patient demographics, age of onset of spinal TB and interventions, types of surgical procedure, intra- and post-operative complications, and neurological status were assessed. . Results. All except one of the 24 patients were treated with anti-TB chemotherapy when they were first diagnosed with spinal TB. They subsequently received surgery either for neurological deterioration, or deformity correction in later life. The mean follow-up was 34 years (11 to 59) since these surgical interventions. Some 16 patients (66.7%) suffered from late neurological deterioration at a mean of 26 years (8 to 49) after the initial drug treatment. The causes of neurological deterioration were healed disease in nine patients (56.2%), re-activation in six patients (37.5%) and adjacent level spinal stenosis in one patient (6.3%). The result of surgery was worse in healed disease. Eight patients without neurological deterioration received surgery to correct the kyphosis. The mean correction ranged from 97° to 72°. Three patients who were clinically quiescent with no neurological deterioration were found to have active TB of the spine. Solid fusion was achieved in all cases and no patient suffered from neurological deterioration after 42 years of follow-up. On final follow-up, six patients were noted to have deceased (age range: 47 years to 75 years). Conclusion. Our study presents one of the longest assessments of spinal TB with severe kyphosis. Severe post-TB kyphosis may lead to significant health problems many years following the initial drug treatment. Early surgical correction of the kyphosis, solid fusion and regular surveillance may avoid late complications. Paraplegia, restrictive lung disease and early onset kyphosis might relate to early death. Clinically quiescent disease does not mean cure. . Cite this article: Bone Joint J 2017;99-B:1381–8

Twenty-two cases of paraplegia complicating injury of the cervical column have been reviewed. The vertebral injury may be due to flexion or hyperextension violence. Flexion injury—There are three types of flexion injury: 1) dislocation; 2) compression fracture of a vertebral body; 3) acute retropulsion of an intervertebral disc. Evidence is presented in support of the view that disc protrusion is the cause of the cord lesion when there is no radiographic evidence of bone injury, and in some cases at least when there is a compression fracture. Treatment is discussed and the indications for caliper traction and laminectomy are presented. Hyperextension injurv—There are two types of hyperextension injury: 1) dislocation; 2) injury to arthritic spines. Hyperextension injury of an arthritic spine is the usual cause of paraplegia in patients over fifty years of age. The mechanism of hyperextension injury is described. The possible causes of spinal cord injury, and its treatment, are discussed

We report the management of two children and 11 adults with paraplegia secondary to vertebral hydatidosis. Destruction of pedicles, posterior vertebral elements and discs as well as the vertebral bodies was common and all six patients with thoracic disease had involvement of adjacent ribs. The 13 patients had a total of 42 major surgical procedures; two patients died from postoperative complications and four from complications of the disease and paraplegia. All eight patients initially treated by laminectomy or anterior decompression alone relapsed within two years and seven required further surgery. Circumferential decompression and grafting gave the best results, six of nine patients being in remission an average of three years and six months later. The prognosis for such patients is poor; remission is the aim, rather than cure. Anthelminthic drugs may improve the prognosis, but radical surgery is likely to remain the keystone of treatment in the foreseeable future

1. In 120 of 740 European patients found to be suffering from spinal tuberculosis the disease was complicated by paraplegia. These 120 patients have been studied. 2. The patients could be divided into two groups: those receiving chemotherapy and those not receiving specific drugs. Chemotherapy improves the patient's general condition and makes operation safer, but does not have any significant effect in preventing paraplegia or in promoting recovery from it. 3. Only twenty-four of the fifty patients treated by closed method made full recovery. 4. The recovery rate after decompression was only 60 per cent. The reasons for this relatively low rate are discussed and the advantages of the postero-lateral approach to the cord, combined with focal operation on the lesion, are stressed. 5. Experience has shown that a policy of early and adequate focal operation can eliminate the risk of this serious complication of spinal tuberculosis. 6. The behaviour of spinal tuberculosis in the European is contrasted with that in the African and Asian

1. The results of treatment of 115 patients with Pott's paraplegia during a six and a half year period are reviewed. 2. The indications for operative intervention—in particular antero-lateral decompression— according to the duration, grade and type of paraplegia, are discussed. 3. No attempt has been made to justify the treatment of individual patients in the series, some of whom would undoubtedly have benefited from earlier operation; but lessons are pointed and conclusions drawn from the results, good and bad

1. Ectopic ossification is commonest in, but not confined to, traumatic paraplegia. It occurs also in many other neurological disorders which have in common a gross disturbance of spinal cord reflex activity. It is a true ossification and must be distinguished from calcification. 2. The neurological lesion may lie anywhere from the cerebral cortex to the mixed peripheral nerve. It may involve motor tracts, sensory tracts or a mixture of both. 3. The ossification is localised and self-limiting. It occurs mainly in the lower limbs and is restricted to certain muscles or muscle groups, the nerve supply of which is always below the level of the central neurological lesion. 4. The blood chemistry is usually normal. 5. A true arthropathy is rare except as part of a secondary suppurative arthritis. 6. The resemblance to myositis ossificans progressiva or to ossifying haematoma is only superficial, although the pathological process at cellular level may be the same. 7. The period of onset after paraplegia is variable. The earliest recorded example is in one of our own cases in which ossification occurred nineteen days after injury. Other patients have developed ossification after several years. 8. The condition is commonest in acquired nervous disease rather than in congenital disorders, and so far as we know it has not been described in the myopathies. The presence of muscular spasticity or flaccidity is relevant only in that it indicates a disturbance of reflex activity. 9. Soft-tissue ulceration appears to be frequently associated with ectopic ossification. The type of new bone formation associated with large chronic ulcers is not to be compared with the new bone formation in the muscles of a paraplegic patient in otherwise good general condition. 10. The occurrence of urinary tract infections with calculi and generalised sepsis is not specifically related to the onset of new bone formation. 11. Localised soft-tissue oedema often precedes the formation of new bone. Its appearance is undoubtedly important, but the mechanism of its origin is obscure. 12. It is not yet known what initiates ectopic ossification, what limits its spread and what finally causes it to stop. 13. We have described 100 examples of ectopic ossification in 603 paraplegic patients. 14. Surgery has been required in only eight patients. The only indication for surgery is bony ankylosis of the hip in an unacceptable position

A case of paraplegia presumed on clinical grounds to be due to bilharziasis is reported. The patient was treated with antibilharzial drugs and steroids. She has been followed up for eight years and has recovered almost completely. The literature is reviewed, and the incidence and types of spinal lesion, the possible routes of infection and the diagnosis and treatment are discussed

Aspergillus infection of the spine is rare; for it to lead to paraplegia is still more rare. When this does occur it is usually treated by decompression and antifungal agents, but the results have usually been poor. We report two cases of successful conservative treatment of Aspergillus paraplegia in patients with chronic granulomatous disease

1. A clinical study has been made of heterotopic ossification in 273 patients with paraplegia of traumatic and non-traumatic origin treated at the Liverpool Paraplegic Centre over a period of twelve and a half years. 2. The literature is reviewed and theories of etiology are discussed. 3. Etiological factors have been studied. Prominent among these is inadequacy of early treatment leading to urinary infection and to the formation of pressure sores. 4. It is concluded that there is no effective treatment for established heterotopic ossification. 5. The importance of prophylactic treatment is stressed. Special emphasis is placed on adequate primary treatment, correction of hypoproteinaemia and early mobilisation

1. Cases of hydatid disease causing paraplegia since 1860 in Great Britain have been briefly reviewed and three recent cases have been added. 2. The types have been classified, the clinical pictures outlined and the treatment discussed

1. The clinical and post-mortem findings are described of a patient who sustained a hyperextension injury of the neck with paraplegia. 2. There was no radiological evidence of fracture: osteoarthritis of the spine was present. 3. Evidence is presented that the cord was damaged from behind by the lamina of the vertebra below a tear in the anterior longitudinal ligament

1. The literature on paraplegia complicating hyperextension injuries of the cervical spine is reviewed, and the lack of any definite explanation of the mode of interference with cord function is noted. 2. A case is described in which a detailed dissection of the post-mortem specimen was carried out. On the basis of the findings it is suggested that one cause of the suppression of cord function in such injuries is thrombosis of the spinal arteries and liquefaction-necrosis of the cord

Paraplegia occurred in an adolescent girl with osteogenesis imperfecta after chiropractic manipulation. The child had been able to walk freely out of doors. Complete motor paralysis with sensory sparing resulted due to anterior compression of the cord by spondyloptotic cervical vertebrae. Reconstructed computerised tomography was very helpful in demonstrating the abnormality. Anterior and then posterior decompression relieved the tethered spinal cord and were supplemented with bone grafting. Early diagnosis and surgical treatment will prevent similar neurological accidents

Twenty-two patients with late onset Pott's paraplegia presenting at a mean of 18 years after initial symptoms were reviewed an average of seven years after treatment by anterior decompression and fusion. Fourteen patients had active disease, and in 12 of these, activity at the internal kyphus was the direct cause of the paraplegia. In the other two, a soft healing bony ridge was the cause. The eight patients with healed disease had hard bony ridges compressing the cord. The response to anterior decompression was faster, better and safer in patients with active disease: nine recovered completely and three significantly. In patients with healed disease, the anterior decompression was technically more difficult and the recovery less satisfactory. Significant complications included two cases with neurological deterioration, two with cerebrospinal fluid fistulae and four with neurapraxia of the cord

1) A case is reported of paraplegia with normal radiographic appearances in which cervical cord damage was shown at autopsy to have been due to hyperextension injury. 2) The mechanism of such injuries is discussed, together with the differential diagnosis from acute prolapse of an intervertebral disc. 3) The grave dangers of using the fully extended position of the cervical spine in the management of these cases is noted

1. Paraplegia from fracture-dislocation at the thoraco-lumbar junction is a mixed cord and root injury. The root damage can be distinguished from cord damage by neurological examination and by comparison of the neurological level with the fracture level. 2. Even though the cord injury is complete, as it usually is, the roots often escape or recover. 3. Fracture-dislocations can be divided into stable and unstable types. Because of the possibility of root recovery care must be taken to prevent further damage to the roots by manipulation of the spine or during treatment. For this reason unstable fracture-dislocations are fixed internally by plates. 4. Internal fixation also assists in the nursing of the patient. The nursing technique and the care of the bladder are described

1. The results of treatment have been compared in two unselected series of patients with unstable fractures of the thoraco-lumbar spine accompanied by paraplegia. 2. One group had been treated by conservative or " postural" methods while the others had been subjected to open reduction and internal fixation with double plates. 3. No difference in the amount of neurological recovery could be detected between the two groups but while a number of conservatively treated patients had significant residual spinal deformity and subsequently developed serious pain, this did not occur in any of the patients treated by plating. 4. It is concluded that open reduction and internal fixation are indicated in displaced fractures in the interests of long-term spinal function

Aims. The outcome following the development of neurological complications after corrective surgery for scoliosis varies from full recovery to a permanent deficit. This study aimed to assess the prognosis and recovery of major neurological deficits in these patients, and to determine the risk factors for non-recovery, at a minimum follow-up of two years. Methods. A major neurological deficit was identified in 65 of 8,870 patients who underwent corrective surgery for scoliosis, including eight with complete paraplegia and 57 with incomplete paraplegia. There were 23 male and 42 female patients. Their mean age was 25.0 years (SD 16.3). The aetiology of the scoliosis was idiopathic (n = 6), congenital (n = 23), neuromuscular (n = 11), neurofibromatosis type 1 (n = 6), and others (n = 19). Neurological function was determined by the American Spinal Injury Association (ASIA) impairment scale at a mean follow-up of 45.4 months (SD 17.2). the patients were divided into those with recovery and those with no recovery according to the ASIA scale during follow-up. Results. The incidence of major deficit was 0.73%. At six-month follow-up, 39 patients (60%) had complete recovery and ten (15.4%) had incomplete recovery; these percentages improved to 70.8% (46) and 16.9% (11) at follow-up of two years, respectively. Eight patients showed no recovery at the final follow-up. The cause of injury was mechanical in 39 patients and ischaemic in five. For 11 patients with misplaced implants and haematoma formation, nine had complete recovery. Fisher’s exact test showed a significant difference in the aetiology of the scoliosis (p = 0.007) and preoperative deficit (p = 0.016) between the recovery and non-recovery groups. A preoperative deficit was found to be significantly associated with non-recovery (odds ratio 8.5 (95% confidence interval 1.676 to 43.109); p = 0.010) in a multivariate regression model. Conclusion. For patients with scoliosis who develop a major neurological deficit after corrective surgery, recovery (complete and incomplete) can be expected in 87.7%. The first three to six months is the time window for recovery. In patients with misplaced implants and haematoma formation, the prognosis is satisfactory with appropriate early intervention. Patients with a preoperative neurological deficit are at a significant risk of having a permanent deficit. Cite this article: Bone Joint J 2022;104-B(1):103–111

Vertebral haemangiomas are usually asymptomatic and discovered fortuitously during imaging. A small proportion may develop variable degrees of pain and neurological deficit. We prospectively studied six patients who underwent eight surgical procedures on 11 vertebral bodies. There were 11 balloon kyphoplasties, six lumbar and five thoracic. The mean follow-up was 22.3 months (12 to 36). The indications for operation were pain in four patients, severe back pain with Frankel grade C paraplegia from cord compression caused by soft-tissue extension from a thoracic vertebral haemangioma in one patient, and acute bleeding causing Frankel grade B paraplegia from an asymptomatic vascular haemangioma in one patient. In four patients the exhibited aggressive vascular features, and two showed lipomatous, non-aggressive, characteristics. One patient who underwent a unilateral balloon kyphoplasty developed a recurrence of symptoms from the non-treated side of the vertebral body which was managed by a further similar procedure. Balloon kyphoplasty was carried out successfully and safely in all patients; four became asymptomatic and two showed considerable improvement. Neurological recovery occurred in all cases but bleeding was greater than normal. To avoid recurrence, complete obliteration of the lesion with bone cement is indicated. For acute bleeding balloon kyphoplasty should be combined with emergency decompressive laminectomy. For intraspinal extension with serious neurological deficit, a combination of balloon kyphoplasty with intralesional alcohol injection is effective

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

1. One hundred and sixty cases of incomplete or complete paraplegia due to extradural malignant tumour have been reviewed. Between 1959 and 1969 laminectomy for decompression of the cord was performed in 154 of these cases as an urgent measure and the results in 129 cases with full records have been assessed. 2. Immediate laminectomy, a palliative procedure, gave worthwhile improvement in 35 percent of cases of incomplete paraplegia; such patients could walk and had satisfactory control of bladder function at least six months after operation. 3. There were no satisfactory results when the paraplegia was complete. 4. The relief of pain following decompression may be gratifying, even if the patient does not improve sufficiently to fulfil the criteria of a satisfactory result. 5. The results emphasise the importance of early diagnosis, myelography and decompression if a patient with incomplete paralysis is to be offered any chance of relief

1. Nine hundred and fourteen cases of tuberculosis of the spine are analysed and the late results ascertained three or more years after discharge from hospital. 2. The relative frequency with which the various segments of the spine are involved has been found. Cervical disease was present in 3·5 per cent of cases, thoracic in 43·l per cent, lumbar in 32·9 per cent, thoraco-lumbar in 16· 7 per cent and lumbo-sacral in 3·8 per cent. 3. The mortality rate was 16·7 per cent. In patients with multiple lesions 25·5 per cent died, compared with 12·3 per cent in the group without complications. When chronic secondarily infected abscesses and sinuses were present the mortality rate was 19·1 per cent, and of patients with paraplegia 24·8 per cent died. 4. In the late results the working capacity of 390 patients was ascertained. It was full in 86 per cent, partial in 5·8 per cent and nil in 8·2 per cent. 5. An attempt has been made to determine the site of the primary bone focus from the radiograph. Early "epiphysial" changes were present in 33 per cent ; the central focus beginning in the spongy tissue of a vertebral body was present in 11·6 per cent; subperiosteal lesions were present in 2·1 per cent; and infection of the neural arch was present in only 0·5 per cent. In 52·8 per cent, however, widespread destruction had taken place when the patient first came under observation. 6. The ill effect of complications upon the prognosis is stressed—especially in the cases of multiple foci of active tuberculosis, secondarily infected abscesses and sinuses, and paraplegia. Paraplegia occurred in 31·2 per cent of the cases of thoracic disease. 7. An attempt has been made to determine the frequency with which tuberculosis of the spine heals by spontaneous bony fusion of the affected vertebral bodies. It was found in 27·3 per cent of the cases in the present series. 8. Reasons for further treatment after the initial discharge of the patient are examined

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

1. The true deformity of kyphoscoliosis has received little attention. Twenty-one deformities of congenital origin, ten idiopathic, and two secondary to neurofibromatosis, are discussed. The diagnosis is established and usually first suspected by radiography. 2. The deformity was severe and progressive except in three cases; paraplegia occurred in five congenital cases. 3. Early correction and fusion are advocated in the hope of preventing paraplegia and because correction of the old-established deformity is difficult or impossible

1. A case is reported of a benign osteoblastoma of the body of the second thoracic vertebra causing paraplegia in a woman aged twenty-six. 2. The tumour was resected, apparently entirely, through a costo-transversectomy approach, and the paraplegia resolved almost completely. 3. Five and a half years later symptoms recurred, due to a recurrence in the form of a large, partly calcified tumour in the left upper thorax which was resected in toto via a transpleural approach. 4. The considerable histological differences between the original tumour and the recurrence are discussed

1. A high incidence of paraplegia following operations for the correction of severe scoliosis in adults led to an investigation of the normal blood supply of the human spinal cord. 2. This entailed three methods of study: micro-dissection of the vessels of the spinal cord in thirty-five cadavers; radiological measurements of the spinal canal in fifty healthy subjects; and a study of the macerated spinal column in six adult cadavers. 3. The blood supply of the spinal cord is shown to be least rich, and the spinal canal narrowest, from the T.4 to approximately the T.9 vertebral level. This is named the critical vascular zone of the spinal cord, the zone in which interference with the circulation is most likely to result in paraplegia

1. Six cases of development of heterotopic bone around joints in association with paralysis from intracranial lesions are presented. It is suggested that such bone may occur more commonly than is realised. 2. The features of these cases are very similar to those seen in association with paraplegia. 3. Extensive new bone is usually associated with fixed contractures. 4. Operation is hazardous in paraplegia but should not necessarily be so in other paralytic conditions. 5. In the presence of returning motor function excision of the bone, allowing correction of the deformity together with some movement, is a worthwhile procedure. In the hip, osteotomy alone usually requires plaster fixation with the attendant risks of venous thrombosis. Previous excision of the bone allows internal fixation of the osteotomy with early mobilisation

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

It is clear that in lateral rhachotomy we have a procedure which is appropriate for approach to the vertebral bodies in a variety of pathological processes including, besides the relief of Pott's paraplegia, the treatment of non-paraplegic tuberculosis, the exploration of spinal tumours, the relief of certain types of traumatic paraplegia and the drainage of suppurative osteitis of the vertebral bodies. For tuberculous disease we find in lateral rhachotomy a technical procedure which provides a meeting point for the solution of several ideas. These are the evacuation of tuberculous abscesses as enunciated by Pott and developed by Ménard, the revascularisation of avascular areas, the removal of necrotic material and the direct removal of the features causing spinal cord compression. It is to the latter only that I think I have made a small contribution. For all other purposes, between lateral rhachotomy and the classical costo-transversectomy, the differences if any are extremely small. The fact remains that the direct surgical approach to lesions of the vertebral bodies has a wide scope of usefulness

Two hundred and eighty-three patients with tuberculosis of the thoracic and/or lumbar spine have been followed for 10 years from the start of treatment. All patients received PAS plus isoniazid daily for 18 months, either with streptomycin for the first three months (SPH) or no streptomycin (PH), by random allocation. There was also a second random allocation for all patients: in Masan to inpatient rest in bed (IP) for six months followed by outpatient treatment or to ambulatory outpatient treatment from the start (OP), and in Pusan to outpatient treatment with a plaster-of-Paris jacket (J) for nine months or to ambulatory treatment without any support (No J). A favourable status was achieved on their allocated regimen by 88% of patients at 10 years. Some of the remaining patients also attained a favourable status after additional chemotherapy and/or operation, and if these are included the proportion achieving such a status increases to 96%. There were five patients whose deaths were attributed to their spinal disease. A sinus or clinically evident abscess was present on at least one occasion in the 10-year period in 42% of the patients. Residual sinuses persisted at 10 years in two patients, at death at seven years in a third and at default in the seventh year in a fourth. Thirty-five patients had paraparesis at some time during the 10-year period, including two who died with paraplegia before five years. Complete resolution occurred in 26 patients (in six after additional chemotherapy and/or surgery). At 10 years two patients had severe paraplegia and one a moderate paraparesis.(ABSTRACT TRUNCATED AT 250 WORDS)

Aims

Implant-related postoperative spondylodiscitis (IPOS) is a severe complication in spine surgery and is associated with high morbidity and mortality. With growing knowledge in the field of periprosthetic joint infection (PJI), equivalent investigations towards the management of implant-related infections of the spine are indispensable. To our knowledge, this study provides the largest description of cases of IPOS to date.

Aims

Patients with differentiated thyroid carcinomas (DTCs) have a favourable long-term survival. Spinal metastases (SMs) cause a decline in performance status (PS), directly affecting mortality and indirectly preventing the use of systemic therapies. Metastasectomy is indicated, if feasible, as it yields the best local tumour control. Our study aimed to examine the long-term clinical outcomes of metastasectomy for SMs of thyroid carcinomas.

Aims

The aims of this study were to determine the incidence and factors for developing periprosthetic joint infection (PJI) following hemiarthroplasty (HA) for hip fracture, and to evaluate treatment outcome and identify factors associated with treatment outcome.

Initial treatment of traumatic spinal cord injury remains as controversial in 2023 as it was in the early 19th century, when Sir Astley Cooper and Sir Charles Bell debated the merits or otherwise of surgery to relieve cord compression. There has been a lack of high-class evidence for early surgery, despite which expeditious intervention has become the surgical norm. This evidence deficit has been progressively addressed in the last decade and more modern statistical methods have been used to clarify some of the issues, which is demonstrated by the results of the SCI-POEM trial. However, there has never been a properly conducted trial of surgery versus active conservative care. As a result, it is still not known whether early surgery or active physiological management of the unstable injured spinal cord offers the better chance for recovery. Surgeons who care for patients with traumatic spinal cord injuries in the acute setting should be aware of the arguments on all sides of the debate, a summary of which this annotation presents.

Cite this article: Bone Joint J 2023;105-B(4):347–355.

Aims

Hip fracture commonly affects the frailest patients, of whom many are care-dependent, with a disproportionate risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England.

Aims

The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI).

Aims

To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus foot deformity.

This review provides a concise outline of the advances made in the care of patients and to the quality of life after a traumatic spinal cord injury (SCI) over the last century. Despite these improvements reversal of the neurological injury is not yet possible. Instead, current treatment is limited to providing symptomatic relief, avoiding secondary insults and preventing additional sequelae. However, with an ever-advancing technology and deeper understanding of the damaged spinal cord, this appears increasingly conceivable. A brief synopsis of the most prominent challenges facing both clinicians and research scientists in developing functional treatments for a progressively complex injury are presented. Moreover, the multiple mechanisms by which damage propagates many months after the original injury requires a multifaceted approach to ameliorate the human spinal cord. We discuss potential methods to protect the spinal cord from damage, and to manipulate the inherent inhibition of the spinal cord to regeneration and repair. Although acute and chronic SCI share common final pathways resulting in cell death and neurological deficits, the underlying putative mechanisms of chronic SCI and the treatments are not covered in this review.

Aims

The aims of this study were to determine the diagnostic yield of image-guided biopsy in providing a final diagnosis in patients with suspected infectious spondylodiscitis, to report the diagnostic accuracy of various microbiological tests and histological examinations in these patients, and to report the epidemiology of infectious spondylodiscitis from a country where tuberculosis (TB) is endemic, including the incidence of drug-resistant TB.

We report two cases of vertebral osteochondroma. In one patient a solitary cervical lesion presented as entrapment neuropathy of the ulnar nerve and in the other as a thoracic tumour associated with hereditary multiple exostoses producing paraplegia. We highlight the importance of an adequate preoperative evaluation in such patients

1. Pyogenic infection of the intervertebral disc in fifteen patients is described. 2. The importance of certain radiological signs in establishing the diagnosis is discussed. 3. Delayed diagnosis is believed to be responsible for the high incidence of paraplegia in this condition. 4. The place of operation in the management of this lesion is considered

Congenital spinal extradural cysts are rare and may be the cause of acute paraplegia. In their clinical features they closely resemble acute transverse myelitis. Immediate decompression of the spinal cord and removal of the cyst may lead to restoration of normal function. Myelography differentiates these two conditions by showing a cyst in communication with the spinal canal. This investigation must be mandatory

A case of cervical traumatic paraplegia is described in which there was no evidence of damage to vertebrae, discs or ligaments. Experimental evidence suggests that such injuries may be caused by inward bulging of the ligamentum flavum during hyperextension. The reasons why this inward bulging may occur, despite the elasticity of the ligamentum flavum, are discussed. Treatment of such cases is considered and the importance of avoiding extension emphasised

1. In children with cerebral palsy and spastic paraplegia or tetraplegia with no fixed fiexion of the knees, tightness of the hamstrings may limit the stride, restrict passive straight leg raising and cause inability to sit up with the knees extended. 2. Nine such children have been treated by bilateral release of the hamstrings from the ischial tuberosity, with marked benefit in all patients

A retrospective survey has been made of forty children with spinal tumours. Difficulties in establishing the correct diagnosis are mentioned and the value of radiological and cerebrospinal fluid investigations discussed. The major orthopaedic disabilities are spinal deformity or instability, and paraplegia. The main factor in the development of the former is the site of laminectomy: the higher the level the greater is the likelihood of deformity or instability developing. Measures to prevent this distressing complication are discussed. The role of the orthopaedic surgeon in the management of these children is emphasised

We compared the usefulness of radiography, CT and MRI in 25 children with spinal tuberculosis. Radiography provided most of the information necessary for diagnosis and treatment. Axial CT was the most accurate method for visualising the posterior bony elements. Sagittal MRI best showed the severity and content of extradural compression and helped to differentiate between an abscess and fibrous tissue. The main value of CT and MRI is in the preoperative evaluation of the small proportion of patients who require surgical treatment for paraplegia

Five cases of syphilitic aortic aneurysm with erosion of the spinal column are reviewed. Four patients underwent operation. When erosion of the spine was mild or moderate, the aortic lesion only was treated. Aneurysm associated with extensive vertebral erosion was treated in two cases by anterior spinal fusion combined with replacement of the disc and part of the aorta. In one of these cases the spine was later reinforced by a posterior spinal fusion. One patient so treated died a week after operation. The patient who refused operation later developed a complete paraplegia

1. The results are recorded of radical excisional surgery for spinal tuberculosis in eighty-five patients. 2. Clinically satisfactory results were obtained in 97 per cent of seventy-one patients followed up. Radiologically the disease was deemed to be cured in 71 per cent of cases. 3. The average period of rest after operation was three and a half months, and the average hospital stay was five and a half months. 4. Total recovery from paraplegia occurred in 84 per cent of patients so affected

Spinal injury at more than one level is not uncommon. Awareness of multilevel injury of the spine and associated neurological patterns is important for the proper initial management of the patient. This study presents the incidence, pattern of signs and the neurological consequences of multilevel spinal injury. A review of 935 patients with spinal injuries revealed that lesions occurred in multiple levels in 9.7%; in over half of the cases, neurological lesions were incomplete. Multiple level non-contiguous lesions at more than two levels had the worst prognosis with 70% of patients suffering complete paraplegia

A survey has been undertaken of the various complications of halo-pelvic distraction in 118 patients with scoliosis prior to spinal fusion. In the first sixty-two patients the standard solid distraction rods were employed. The neurological complications included ten cases of cranial nerve lesions and two cases of paraplegia, one of them permanent. Springs were then incorporated in the distraction rods so as to allow direct readings ofthe distraction forces, and a total force of 18 kilograms was not exceeded in the last fifty-six patients. No further serious neurological complications occurred, but the amount of correction achieved in the adolescent and juvenile idiopathic types of scoliosis was reduced

1. Twenty-eight patients with pyogenic infection of the spine are reported. 2. Diagnosis was by clinical, radiological and bacteriological means. Investigations of the spinal lesions by needle aspiration or open operation was needed in four patients. 3. Treatment consisted primarily of antibiotics and rest. 4. Twenty-five patients were fit and well after follow-up of one to fifteen years. Three deaths occurred, but only one was directly connected with the infection ; urinary infection with paraplegia and haemophilia were the cause in two others. 5. The relatively benign course is stressed, as are some of the diagnostic pitfalls in the early stages, particularly with thoracic lesions

Twenty-eight patients with adolescent idiopathic scoliosis treated by anterior spinal fusion with Dwyer instrumentation were reviewed. The average length of follow-up was 6.9 years. This technique produced better correction of lateral curvature and rotation than Harrington instrumentation, particularly in the thoracolumbar and lumbar region. The length of spine requiring fusion was also shorter. There is, however, a tendency for Dwyer instrumentation to lead to kyphosis. Morbidity was significant and included one case of paraplegia, four cases of deep infection and one case of instrument failure. All of these complications, except one case of deep infection, occurred in patients with curves with an apex above the seventh thoracic vertebra

Total removal of the third thoracic vertebra and partial removal of the second and fourth vertebrae together with partial lung resection were successfully performed in a twenty-two-year-old woman with a large, radioresistant, giant-cell tumour which completely surrounded the spinal cord and extended over the left lung. On admission, the patient was in her third episode of paraplegia, the two previous episodes having been temporarily relieved after decompression of the spinal cord by laminectomy and partial removal of the tumour. Three and a half months after operation she was discharged walking without support and with normal sphincter control. Two years later she is free of symptoms and the neurological status is practically normal. Clinical and radiological examinations show no signs of recurrence of the tumour

1. The management of severe kyphosis of the lumbar spine in association with myelomeningocele is discussed. 2. Neonatal spinal osteotomy-resection has been performed in six patients with partial correction of the deformity and a greatly improved ease of closure and healing of the skin defect. The severity of lower limb paralysis has been diminished compared with the complete paraplegia that almost always results from conservative management of closure of the defect without osteotomy. 3. In an older child who has not had the benefit of neonatal osteotomy and who has complete lower limb paralysis, transverse spinal osteotomy or excision of the prominent laminae and pedicles on each side of the midline makes possible the fitting of apparatus for walking and diminishes the liability to recurrent ulceration of the skin

Sixty patients with congenital deformities of the spine were operated upon in the past fifteen years using a two-stage procedure. In the fifty patients with scoliosis half of the deformities were due to hemivertebrae and half to unilateral bars. The average correction of the deformity was 47 per cent. Early neurological signs observed in two patients with a diastematomyelia resolved. Of the ten patients with kyphosis nine had neurological signs of impending paraplegia and one was completely paraplegic before operation; all improved markedly. Posterior spinal fusion alone in the rapidly progressing congenital deformity may not prevent further progression, particularly in those cases iwth unilateral bars. Anterior resection of the vertebral body with later posterior fusion with Harrington instrumentation is safe and effective

1. A syndrome resulting from congenital lesions affecting the spinal cord and cauda equina, associated with spina bifida occulta, is described. 2. The syndrome consists of a progressive deformity of the lower limbs in children. One foot and the same leg grow less rapidly than the other. The foot develops a progressive deformity which begins as a cavo-varus and becomes a valgus one. Both lower limbs may be affected. There may be progression to sensory loss, trophic ulceration, disturbance of function of bowel and bladder and even paraplegia. 3. Methods of investigation including myelography are described. 4. Exploration of the spinal cord has been undertaken in twenty-four patients so affected. Extrinsic congenital lesions causing traction or pressure or a combination of traction and pressure on the spinal cord have been found in twenty-two of these. 5. In two-thirds of the patients some degree of improvement has followed operation

Everywhere I visited, both in England and in other parts of Europe, I met with wonderful hospitality and friendliness. Generally our common language was English, and I felt thoroughly ashamed of my poor efforts at speaking other languages. During my tour in England, France, Germany, Austria, Italy, Denmark, Norway and Sweden I heard many new ideas propounded, and have seen many new and different methods of treatment. In particular I have been able to compare thoughts on such subjects as tuberculosis of the spine, congenital dislocation of the hip, osteoarthritis of the hip, scoliosis, many aspects of trauma, Perthes' disease, hand surgery, poliomyelitis, paraplegia, the treatment of cerebral palsy, rehabilitation of patients suffering from all kinds of orthopaedic disabilities, and surgical appliances. I am very grateful indeed to the British Orthopaedic Association for making this six-months' tour possible

We performed a randomised, controlled clinical trial to compare ambulant short-course chemotherapy with anterior spinal fusion plus short-course chemotherapy for spinal tuberculosis without paraplegia. Patients with active disease of vertebral bodies were randomly allocated to one of three regimens: a) radical anterior resection with bone grafting plus six months of daily isoniazid plus rifampicin (Rad6); b) ambulant chemotherapy for six months with daily isoniazid plus rifampicin (Amb6); or c) similar to b) but with chemotherapy for nine months (Amb9). Ten years from the onset of treatment, 90% of 78 Rad6, 94% of 78 Amb6 and 99% of 79 Amb9 patients had a favourable status. Ambulant chemotherapy for a period of six months with daily isoniazid plus rifampicin (Amb6) was an effective treatment for spinal tuberculosis except in patients aged less than 15 years with an initial angle of kyphosis of more than 30° whose kyphosis increased substantially

We have reviewed 41 patients with malignant extradural tumours of the spine treated by anterior decompression for cord compression, or uncontrolled back pain or both. An anterior operation alone was performed in 37 cases, four had combined or staged anterior and posterior decompression. An anterior operation on its own achieved major neurological recovery in 18 of the 33 cases with neurological loss (56%); only four remained unchanged. Eleven had minor improvement but not enough to allow them to walk or to regain bladder function. No patient with complete paraplegia gained a useful neurological recovery. Back pain was improved in 30 of the 41 patients (73%), sound internal fixation being important in this respect. There were four early deaths and another 23 died from disseminated disease after a mean survival of 4.1 months. Fourteen patients are still alive with a mean survival of 14 months

Thirteen patients, aged 7 to 45 years, have been treated for atypical forms of spinal tuberculosis at the Neurological Centres at Benghazi and Lahore. All presented with signs and symptoms of compression of the spinal cord or cauda equina, ranging from paraesthesiae and increasing weakness to paraplegia and loss of sphincter control. None of them showed visible or palpable spinal deformity nor the typical radiographic appearance of destruction of the intervertebral disc and the two adjoining vertebral bodies. These atypical cases fell into two well-defined groups: those with involvement of the neural arch only, with associated intraspinal cold abscesses, and those with involvement of a single vertebral body, resulting in its collapse and a radiographic appearance similar to that in secondary carcinoma of the vertebral body. The correct treatment in these two groups was diametrically opposed. Tuberculous disease of the neural arch was best traced by laminectomy; concertina collapse of a single vertebral body required cost-transversectomy and resection of the transverse process, the pedicle, and the portion of the vertebral body that was encroaching on the spinal canal

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°

Seat-belt fractures of the lumbar spine in adolescents and adults are well recognised but there are few reports of these injuries in young children. We reviewed all seat-belt injuries in skeletally immature patients (Risser 0), seen at a tertiary referral centre between 1974 and 1991. There were ten cases, eight girls and two boys, with an average age of 7.5 years (3 to 13). Four distinct patterns of injury were observed, most commonly at the L2 to L4 level. Paraplegia, which is thought to be uncommon, occurred in three of our ten cases. Four children had intra-abdominal injuries requiring laparotomy. There was a delay in diagnosis either of the spinal or of the intra-abdominal injury in five cases, although all had contusion of the abdominal wall, the 'seat-belt sign'. Treatment of the fractures was conservative, by bed rest and then hyperextension casts. The incidence of this potentially devastating injury can be reduced by the optimal use of restraints, but there is often a delay in diagnosis. Our classification system may aid in the early detection and evaluation of this injury

Aims

To investigate the impact of the Charlson and Elixhauser comorbidity indices on patient-reported outcomes measures (PROMs) following shoulder arthroplasty.

The final results up to 15 years are reported of clinical trials of the management of tuberculosis of the spine in Korea and Hong Kong. In Korea, 350 patients with active spinal tuberculosis were randomised to ambulatory chemotherapy or bed rest in hospital (in Masan) or a plaster-of-Paris jacket for nine months (in Pusan). Patients in both centres were also randomised to either PAS plus isoniazid for 18 months or to the same drugs plus streptomycin for the first three months. In Hong Kong, all 150 patients were treated with the three-drug regime and randomised to either radical excision of the spinal lesion with bone graft or open debridement. On average, the disease was more extensive in Korea, but at 15 years (or 13 or 14 years in a proportion of the patients in Korea) the great majority of patients in both countries achieved a favourable status, no evidence of CNS involvement, no radiological evidence of disease, no sinus or clinically evident abscess, and no restriction of normal physical activity. Most patients had already achieved a favourable status much earlier. The earlier results of these trials are confirmed by the long-term follow-up with no late relapse or late-onset paraplegia. The results of chemotherapy on an outpatient basis were not improved by bed rest or a plaster jacket and the only advantage of the radical operation was less late deformity compared with debridement. A second series of studies has shown that short-course regimes based on isoniazid and rifampicin are as effective as the 18-month regimes: ambulatory chemotherapy with these regimes should now be the main management of uncomplicated spinal tuberculosis

Aims

To develop and externally validate a parsimonious statistical prediction model of 90-day mortality after elective total hip arthroplasty (THA), and to provide a web calculator for clinical usage.

Aims

This study, using a surgeon-maintained database, aimed to explore the risk factors for surgery-related complications in patients undergoing primary cervical spine surgery for degenerative diseases.

Aims

Whether a combined anteroposterior fusion or a posterior-only fusion is more effective in the management of patients with Scheuermann’s kyphosis remains controversial. The aim of this study was to compare the radiological and clinical outcomes of these surgical approaches, and to evaluate the postoperative complications with the hypothesis that proximal junctional kyphosis would be more common in one-stage posterior-only fusion.

In two centres in Korea 350 patients with a diagnosis of tuberculosis of the thoracic and/or lumbar spine were allocated at random: in Masan to in-patient rest in bed (IP) for six months followed by out-patient treatment or to ambulatory out-patient treatment (OP) from the start; in Pusan to out-patient treatment with a plaster-of-Paris jacket (J) for nine months or to ambulatory treatment without any support (No J). All patients recieved chemotherapy with PAS with isoniazid for eighteen months, either supplemented with streptomycin for the first three months (SPH) or without this supplement (PH), by random allocation. The main analysis of this report concerns 299 patients (eighty-three IP, eighty-three OP, sixty-three J, seventy No J; 143 SPH, 156 PH). Pre-treatment factors were similar in both centres except that the patients in Pusan had, on average, less extensive lesions although in a greater proportion the disease was radiographically active. One patient (J/SPH) died with active spinal disease and three (all No J/SPH) with paraplegia. A fifth patient (IP/PH) who died from cardio respiratory failure also had pulmonary tuberculosis. Twenty-three patients required operation and/or additional chemotherapy for the spinal lesion. A sinus or clinically evident abscess was either present initially or developed during treatment in 41 per cent of patients. Residual lesions persisted in ten patients (four IP, two OP, one J, three No J; six SPH, four PH) at five years. Thirty-two patients had paraparesis on admission or developing later. Complete resolution occurred in twenty on the allocated regimen and in eight after operation or additional chemotherapy or both. Of the remaining four atients, all of whom had operation and additional chemotherapy, three died and one still had paraparesis at five years. Of 295 patients assessed at five years 89 per cent had a favourable status. The proportions of the patients responding favourably were similar in the IP (91 per cent) and OP (89 per cent) series, in the J (90 per cent) and No J (84 per cent) series and in the SPH (86 per cent) and PH (92 per cent) series

1. Two hundred young Korean patients with a diagnosis of tuberculosis of the spine were allocated at random to in-patient rest in bed (IP) for six months followed by out-patient treatment, or to ambulatory out-patient treatment (OP) from the start. A second random allocation was made to chemotherapy with streptomycin for three months and PAS plus isoniazid for eighteen months (SPH), or to PAS plus isoniazid for eighteen months (PH). For various reasons twenty-nine patients had to be excluded from the study. The main analyses of this report therefore concern 171 patients, namely, forty IP/SPH, forty-six IP/PH, forty-two OP/SPH and forty three OP/PH. The comparisons made are a) of in-patient and out-patient treatment, and b) of the SPH and PH regimens. 2. The clinical and radiographic condition of the four groups on admission was similar. Many patients had extensive lesions. 3. Two in-patients died, probably from miliary tuberculosis, but neither had evidence of residual activity of the spinal lesion. 4. For the eighty-six in-patients the mean stay in hospital was 199 days and five were later readmitted. Of the eighty-five out-patients twenty-one (fourteen SPH, seven PH) were admitted to hospital in the first six months for complications of the spinal disease, for other medical conditions, or for domestic or geographical reasons; after the first six months eight more were admitted. 5. Three in-patients and five out-patients received chemotherapy beyond eighteen months for abscess or for paraparesis. 6. An abscess or sinus was either present initially or developed during treatment in 76 per cent of the in-patients and 72 per cent of the out-patients. Complete resolution occurred in most of the patients, some abscesses being aspirated. At three years 11 per cent of the in-patients and 5 per cent of the out-patients still had residual abscesses or sinuses. 7. On admission the mean total vertebral loss was 1·79 in the in-patients and 1·33 in the out-patients, and increased over the three-year period by 0·15 and 0·31 respectively. 8. The mean angulation of the spine at the start of treatment was 37 degrees for the in-patients and 27 degrees for the out-patients, the mean increase over the three-year period being 8 and 18 degrees respectively. 9. On admission six in-patients and four out-patients had incomplete motor paraplegia. This resolved completely within nine months in eight patients, as did the one cauda equina lesion. Only two patients (both out-patients) developed paraparesis during the course of the study; both recovered. 10. At eighteen months 66 per cent of the in-patients and 58 per cent of the out-patients had responded favourably. The corresponding percentages at thirty-six months were 84 and 88. 11. There was little difference in behaviour between the SPH and the PH series; at thirty-six months 82 per cent of eighty SPH and 90 per cent of eighty-eight PH patients had a favourable response. 12. A multiple regression analysis failed to identify any factor of clearly prognostic importance on admission

Cell therapies hold significant promise for the treatment of injured or diseased musculoskeletal tissues. However, despite advances in research, there is growing concern about the increasing number of clinical centres around the world that are making unwarranted claims or are performing risky biological procedures. Such providers have been known to recommend, prescribe, or deliver so called ‘stem cell’ preparations without sufficient data to support their true content and efficacy. In this annotation, we outline the current environment of stem cell-based treatments and the strategies of marketing directly to consumers. We also outline the difficulties in the regulation of these clinics and make recommendations for best practice and the identification and reporting of illegitimate providers.

Cite this article: Bone Joint J 2020;102-B(2):148–154

Tuberculosis (TB) remains endemic in many parts of the developing world and is increasingly seen in the developed world due to migration. A total of 1.3 million people die annually from the disease. Spinal TB is the most common musculoskeletal manifestation, affecting about 1 to 2% of all cases of TB. The coexistence of HIV, which is endemic in some regions, adds to the burden and the complexity of management.

This review discusses the epidemiology, clinical presentation, diagnosis, impact of HIV and both the medical and surgical options in the management of spinal TB.

Cite this article: Bone Joint J 2018;100-B:425–31.

Aims

The aim of the study was to compare measures of the quality of life (QOL) after resection of a chordoma of the mobile spine with the national averages in the United States and to assess which factors influenced the QOL, symptoms of anxiety and depression, and coping with pain post-operatively in these patients.

Aims

The aims of this study were to characterize the frequency of missing data in the National Surgical Quality Improvement Program (NSQIP) database and to determine how missing data can influence the results of studies dealing with elderly patients with a fracture of the hip.

Aims

Our aim was to examine the Elixhauser and Charlson comorbidity indices, based on administrative data available before surgery, and to establish their predictive value for mortality for patients who underwent hip arthroplasty in the management of a femoral neck fracture.

The mucopolysaccharidoses (MPS) are a group of inherited lysosomal storage disorders with clinical manifestations relevant to the orthopaedic surgeon. Our aim was to review the recent advances in their management and the implications for surgical practice.

The current literature about MPSs is summarised, emphasising orthopaedic complications and their management.

Recent advances in the diagnosis and management of MPSs include the recognition of slowly progressive, late presenting subtypes, developments in life-prolonging systemic treatment and potentially new indications for surgical treatment. The outcomes of surgery in these patients are not yet validated and some procedures have a high rate of complications which differ from those in patients who do not have a MPS.

The diagnosis of a MPS should be considered in adolescents or young adults with a previously unrecognised dysplasia of the hip. Surgeons treating patients with a MPS should report their experience and studies should include the assessment of function and quality of life to guide treatment.

Cite this article: Bone Joint J 2017;99-B:1132–9

We assessed the frequency and causes of neurological deterioration in 59 patients with spinal cord injury on whom reports were prepared for clinical negligence litigation. In those who deteriorated neurologically we assessed the causes of the change in neurology and whether that neurological deterioration was potentially preventable. In all 27 patients (46%) changed neurologically, 20 patients (74% of those who deteriorated) had no primary neurological deficit. Of those who deteriorated, 13 (48%) became Frankel A. Neurological deterioration occurred in 23 of 38 patients (61%) with unstable fractures and/or dislocations; all 23 patients probably deteriorated either because of failures to immobilise the spine or because of inappropriate removal of spinal immobilisation. Of the 27 patients who altered neurologically, neurological deterioration was, probably, avoidable in 25 (excess movement in 23 patients with unstable injuries, failure to evacuate an epidural haematoma in one patient and over-distraction following manipulation of the cervical spine in one patient). If existing guidelines and standards for the management of actual or potential spinal cord injury had been followed, neurological deterioration would have been prevented in 25 of the 27 patients (93%) who experienced a deterioration in their neurological status.

Cite this article: Bone Joint J 2015;97-B:527–31.

Aims

The aim of this study was to compare the outcomes of surgery using growing rods in patients with severe versus moderate early-onset scoliosis (EOS).

We have reviewed our experience in managing 11 patients who sustained an indirect sternal fracture in combination with an upper thoracic spinal injury between 2003 and 2006. These fractures have previously been described as ‘associated’ fractures, but since the upper thorax is an anatomical entity composed of the upper thoracic spine, ribs and sternum joined together, we feel that the term ‘fractures of the upper transthoracic cage’ is a better description. These injuries are a challenge because they are unusual and easily overlooked. They require a systematic clinical and radiological examination to identify both lesions. This high-energy trauma gives severe devastating concomitant injuries and CT with contrast and reconstruction is essential after resuscitation to confirm the presence of all the lesions. The injury level occurs principally at T4–T5 and at the manubriosternal joint. These unstable fractures need early posterior stabilisation and fusion or, if treated conservatively, a very close follow-up.

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.

Injury to the spinal cord and kyphosis are the two most feared complications of tuberculosis of the spine. Since tuberculosis affects principally the vertebral bodies, anterior decompression is usually recommended. Concomitant posterior instrumentation is indicated to neutralise gross instability from panvertebral disease, to protect the anterior bone graft, to prevent graft-related complications after anterior decompression in long-segment disease and to correct a kyphosis. Two-stage surgery is usually performed in these cases. We present 38 consecutive patients with tuberculosis of the spine for whom anterior decompression, posterior instrumentation, with or without correction of the kyphus, and anterior and posterior fusion was performed in a single stage through an anterolateral extrapleural approach. Their mean age was 20.4 years (2.0 to 57.0).

The indications for surgery were panvertebral disease, neurological deficit and severe kyphosis. The patients were operated on in the left lateral position using a ‘T’-shaped incision sited at the apex of kyphosis or lesion. Three ribs were removed in 34 patients and two in four and anterior decompression of the spinal cord was carried out. The posterior vertebral column was shortened to correct the kyphus, if necessary, and was stabilised by a Hartshill rectangle and sublaminar wires. Anterior and posterior bone grafting was performed.

The mean number of vertebral bodies affected was 3.24 (2.0 to 9.0). The mean pre-operative kyphosis in patients operated on for correction of the kyphus was 49.08° (30° to 72°) and there was a mean correction of 25° (6° to 42°). All except one patient with a neural deficit recovered complete motor and sensory function. The mean intra-operative blood loss was 1175 ml (800 to 2600), and the mean duration of surgery 3.5 hours (2.7 to 5.0). Wound healing was uneventful in 33 of 38 patients. The mean follow-up was 33 months (11 to 74). None of the patients required intensive care.

The extrapleural anterolateral approach provides simultaneous exposure of the anterior and posterior aspects of the spine, thereby allowing decompression of the spinal cord, posterior stabilisation and anterior and posterior bone grafting. This approach has much less morbidity than the two-stage approaches which have been previously described.

While an increasing amount of arthroplasty articles report comorbidity measures, none have been validated for outcomes. In this study, we compared commonly used International Classification of Diseases-based comorbidity measures with re-operation rates after total hip replacement (THR). Scores used included the Charlson, the Royal College of Surgeons Charlson, and the Elixhauser comorbidity score. We identified a nationwide cohort of 134 423 THRs from the Swedish Hip Arthroplasty Register. Re-operations were registered post-operatively for up to 12 years. The hazard ratio was estimated by Cox’s proportional hazards regression, and we used C-statistics to assess each measure’s ability to predict re-operation. Confounding variables were age, gender, type of implant fixation, hospital category, hospital implant volume and year of surgery.

In the first two years only the Elixhauser score showed any significant relationship with increased risk of re-operation, with increased scores for both one to two and three or more comorbidities. However, the predictive C-statistic in this period for the Elixhauser score was poor (0.52). None of the measures proved to be of any value between two and 12 years. They might be of value in large cohort or registry studies, but not for the individual patient.

Cite this article: Bone Joint J 2013;95-B:1184–91.

Between 1998 and 2007, 22 patients with fractures of the scapula had operative treatment more than three weeks after injury. The indications for operation included displaced intra-articular fractures, medialisation of the glenohumeral joint, angular deformity, or displaced double lesions of the superior shoulder suspensory complex.

Radiological and functional outcomes were obtained for 16 of 22 patients. Disabilities of the Arm, Shoulder, Hand (DASH) and Short form-36 scores were collected for 14 patients who were operated on after March 2002. The mean delay from injury to surgery was 30 days (21 to 57). The mean follow-up was for 27 months (12 to 72). At the last review the mean DASH score was 14 (0 to 41). Of the 16 patients with follow-up, 13 returned to their previous employment and recreational activities without restrictions. No wound complications, infection or nonunion occurred.

Malunion of the scapula can be prevented by surgical treatment of fractures in patients with delayed presentation. Surgery is safe, effective, and gives acceptable functional results.

The aim of this study was to define return to theatre (RTT) rates for elective hip and knee replacement (HR and KR), to describe the predictors and to show the variations in risk-adjusted rates by surgical team and hospital using national English hospital administrative data.

We examined information on 260 206 HRs and 315 249 KRs undertaken between April 2007 and March 2012. The 90-day RTT rates were 2.1% for HR and 1.8% for KR. Male gender, obesity, diabetes and several other comorbidities were associated with higher odds for both index procedures. For HR, hip resurfacing had half the odds of cement fixation (OR = 0.58, 95% confidence intervals (CI) 0.47 to 0.71). For KR, unicondylar KR had half the odds of total replacement (OR = 0.49, 95% CI 0.42 to 0.56), and younger ages had higher odds (OR = 2.23, 95% CI 1.65 to 3.01) for ages < 40 years compared with ages 60 to 69 years). There were more funnel plot outliers at three standard deviations than would be expected if variation occurred on a random basis.

Hierarchical modelling showed that three-quarters of the variation between surgeons for HR and over half the variation between surgeons for KR are not explained by the hospital they operated at or by available patient factors. We conclude that 90-day RTT rate may be a useful quality indicator for orthopaedics.

Cite this article: Bone Joint J 2014; 96-B:1663–8.

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 report the incidence of and risk factors for complications after scoliosis surgery in patients with Duchenne muscular dystrophy (DMD) and compare them with those of other neuromuscular conditions.

We identified 110 (64 males, 46 females) consecutive patients with a neuromuscular disorder who underwent correction of the scoliosis at a mean age of 14 years (7 to 19) and had a minimum two-year follow-up. We recorded demographic and peri-operative data, including complications and re-operations.

There were 60 patients with cerebral palsy (54.5%) and 26 with DMD (23.6%). The overall complication rate was 22% (24 patients), the most common of which were deep wound infection (9, 8.1%), gastrointestinal complications (5, 4.5%) and hepatotoxicity (4, 3.6%). The complication rate was higher in patients with DMD (10/26, 38.5%) than in those with other neuromuscular conditions (14/84, 16.7% (p = 0.019). All hepatotoxicity occurred in patients with DMD (p = 0.003), who also had an increased rate of deep wound infection (19% vs 5%) (p = 0.033). In the DMD group, no peri-operative factors were significantly associated with the rate of overall complications or deep wound infection. Increased intra-operative blood loss was associated with hepatotoxicity (p = 0.036).

In our series, correction of a neuromuscular scoliosis had an acceptable rate of complications: patients with DMD had an increased overall rate compared with those with other neuromuscular conditions. These included deep wound infection and hepatotoxicity. Hepatotoxicity was unique to DMD patients, and we recommend peri-operative vigilance after correction of a scoliosis in this group.

Cite this article: Bone Joint J 2014; 96-B:943–9.