The aim of this study was first, to determine whether CT scans undertaken to identify serious injury to the viscera were of use in detecting clinically unrecognised fractures of the thoracolumbar vertebrae, and second, to identify patients at risk of ‘missed injury’. . We retrospectively analysed CT scans of the chest and abdomen performed for blunt injury to the torso in 303 patients. These proved to be positive for thoracic and intra-abdominal injuries in only 2% and 1.3% of cases, respectively. However, 51 (16.8%) showed a fracture of the thoracolumbar vertebrae and these constituted our subset for study. There were eight women and 43 men with mean age of 45.2 years (15 to 94). There were 29 (57%) stable and 22 (43%) unstable fractures. Only 17 fractures (33.3%) had been anticipated after clinical examination. Of the 22 unstable fractures, 11 (50%) were anticipated. Thus, within the whole group of 303 patients, an unstable spinal injury was missed in 11 patients (3.6%); no harm resulted as they were all protected until the spine had been cleared. A subset analysis revealed that patients with a high Injury Severity Score, a low Glasgow Coma Scale and haemodynamic instability were most likely to have a significant fracture in the absence of positive clinical findings. This is the group at greatest risk. Clinical examination alone cannot detect significant fractures of the thoracolumbar spine. It should be combined with CT imaging to reduce the risk of missed injury

Aims. The aim of this study was to assess the reliability of using MRI scans to calculate the Spinal Instability Neoplastic Score (SINS) in patients with metastatic spinal cord compression (MSCC). Methods. A total of 100 patients were retrospectively included in the study. The SINS score was calculated from each patient’s MRI and CT scans by two consultant musculoskeletal radiologists (reviewers 1 and 2) and one consultant spinal surgeon (reviewer 3). In order to avoid potential bias in the assessment, MRI scans were reviewed first. Bland-Altman analysis was used to identify the limits of agreement between the SINS scores from the MRI and CT scans for the three reviewers. Results. The limit of agreement between the SINS score from the MRI and CT scans for the reviewers was -0.11 for reviewer 1 (95% CI 0.82 to -1.04), -0.12 for reviewer 2 (95% CI 1.24 to -1.48), and -0.37 for reviewer 3 (95% CI 2.35 to -3.09). The use of MRI tended to increase the score when compared with that using the CT scan. No patient having their score calculated from MRI scans would have been classified as stable rather than intermediate or unstable when calculated from CT scans, potentially leading to suboptimal care. Conclusion. We found that MRI scans can be used to calculate the SINS score reliably, compared with the score from CT scans. The main difference between the scores derived from MRI and CT was in defining the type of bony lesion. This could be made easier by knowing the site of the primary tumour when calculating the score, or by using inverted T1-volumetric interpolated breath-hold examination MRI to assess the bone more reliably, similar to using CT. Cite this article: Bone Joint J 2021;103-B(5):971–975

Aims. To benchmark the radiation dose to patients during the course of treatment for a spinal deformity. Methods. Our radiation dose database identified 25,745 exposures of 6,017 children (under 18 years of age) and adults treated for a spinal deformity between 1 January 2008 and 31 December 2016. Patients were divided into surgical (974 patients) and non-surgical (5,043 patients) cohorts. We documented the number and doses of ionizing radiation imaging events (radiographs, CT scans, or intraoperative fluoroscopy) for each patient. All the doses for plain radiographs, CT scans, and intraoperative fluoroscopy were combined into a single effective dose by a medical physicist (milliSivert (mSv)). Results. There were more ionizing radiation-based imaging events and higher radiation dose exposures in the surgical group than in the non-surgical group (p < 0.001). The difference in effective dose for children between the surgical and non-surgical groups was statistically significant, the surgical group being significantly higher (p < 0.001). This led to a higher estimated risk of cancer induction for the surgical group (1:222 surgical vs 1:1,418 non-surgical). However, the dose difference for adults was not statistically different between the surgical and non-surgical groups. In all cases the effective dose received by all cohorts was significantly higher than that from exposure to natural background radiation. Conclusion. The treatment of spinal deformity is radiation-heavy. The dose exposure is several times higher when surgical treatment is undertaken. Clinicians should be aware of this and review their practices in order to reduce the radiation dose where possible. Cite this article: Bone Joint J 2021;103-B(4):1–7

Aims. Although lumbosacral transitional vertebrae (LSTV) are well-documented, few large-scale studies have investigated thoracolumbar transitional vertebrae (TLTV) and spinal numerical variants. This study sought to establish the prevalence of numerical variants and to evaluate their relationship with clinical problems. Methods. A total of 1,179 patients who had undergone thoracic, abdominal, and pelvic CT scanning were divided into groups according to the number of thoracic and lumbar vertebrae, and the presence or absence of TLTV or LSTV. The prevalence of spinal anomalies was noted. The relationship of spinal anomalies to clinical symptoms (low back pain, Japanese Orthopaedic Association score, Roland-Morris Disability Questionnaire) and degenerative spondylolisthesis (DS) was also investigated. Results. Normal vertebral morphology (12 thoracic and five lumbar vertebrae without TLTV and LSTV) was present in 531 male (76.7%) and 369 female patients (75.8%). Thoracolumbar transitional vertebrae were present in 15.8% of males and 16.0% of females. LSTV were present in 7.1% of males and 9.0% of females. The prevalence of the anomaly of 16 presacral mobile vertebrae (total number of thoracolumbar vertebrae and TLTV) without LSTV was 1.0% in males and 4.1% in females, and that of the anomaly of 18 vertebrae without LSTV was 5.3% in males and 1.2% in females. The prevalence of DS was significantly higher in females with a total of 16 vertebrae than in those with normal morphology. There was no significant correlation between a spinal anomaly and clinical symptoms. Conclusion. Overall, 24% of subjects had anomalies in the thoracolumbar region: the type of anomaly differed between males and females, which could have significant implications for spinal surgery. A decreased number of vertebrae was associated with DS: numerical variants may potentially be a clinical problem. Cite this article: Bone Joint J 2021;103-B(7):1301–1308

Aims. Although we often encounter patients with an aortic aneurysm who also have diffuse idiopathic skeletal hyperostosis (DISH), there are no reports to date of an association between these two conditions and the pathogenesis of DISH remains unknown. This study therefore evaluated the prevalence of DISH in patients with a thoracic aortic aneurysm (AA). Patients and Methods. The medical records of 298 patients who underwent CT scans for a diagnosis of an AA or following high-energy trauma were retrospectively examined. A total of 204 patients underwent surgery for an AA and 94 had a high-energy injury and formed the non-AA group. The prevalence of DISH was assessed on CT scans of the chest and abdomen and the relationship between DISH and AA by comparison between the AA and non-AA groups. Results. The prevalence of DISH in the AA group (114/204; 55.9%) was higher than that in the non-AA group (31/94; 33.0%). On multivariate analysis, the factors of AA, male gender, and ageing were independent predictors of the existence of DISH, with odds ratios of 2.9, 1.9, and 1.03, respectively. Conclusion. This study revealed that the prevalence of DISH is higher in patients with an AA than in those without an AA, and that the presence of an AA significantly influenced the prevalence of DISH. Cite this article: Bone Joint J 2018;100-B:617–21

Aims. 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). Patients and Methods. 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. Results. High accuracy was achieved in 524 screws (88.5%), 192 (87.7%) in the cervical spine and 332 (89%) in the thoracic spine, respectively. The results in the two surgical groups were compared and a logistic regression mixed model was performed to analyse the risk of low accuracy. Significantly lower accuracy was found in the COMB group with 82.9% versus 91.6% in the POST group (p = 0.036). There were no neurological complications, but two vertebral artery lesions were recorded. Three patients underwent revision surgery for malpositioning of a screw. Although the risk of malpositioning of a screw after primary anterior surgery was estimated to be 2.4-times higher than with posterior surgery alone, the overall rates of complication and revision were low. Conclusion. We therefore conclude that CT navigated pedicle screws can be positioned safely although greater caution must be taken in patients who have previously undergone anterior surgery. Cite this article: Bone Joint J 2017;99-B:1373–80

Objectives. Cement augmentation of pedicle screws could be used to improve screw stability, especially in osteoporotic vertebrae. However, little is known concerning the influence of different screw types and amount of cement applied. Therefore, the aim of this biomechanical in vitro study was to evaluate the effect of cement augmentation on the screw pull-out force in osteoporotic vertebrae, comparing different pedicle screws (solid and fenestrated) and cement volumes (0 mL, 1 mL or 3 mL). Materials and Methods. A total of 54 osteoporotic human cadaver thoracic and lumbar vertebrae were instrumented with pedicle screws (uncemented, solid cemented or fenestrated cemented) and augmented with high-viscosity PMMA cement (0 mL, 1 mL or 3 mL). The insertion torque and bone mineral density were determined. Radiographs and CT scans were undertaken to evaluate cement distribution and cement leakage. Pull-out testing was performed with a material testing machine to measure failure load and stiffness. The paired t-test was used to compare the two screws within each vertebra. Results. Mean failure load was significantly greater for fenestrated cemented screws (+622 N; p ⩽ 0.001) and solid cemented screws (+460 N; p ⩽ 0.001) than for uncemented screws. There was no significant difference between the solid and fenestrated cemented screws (p = 0.5). In the lower thoracic vertebrae, 1 mL cement was enough to significantly increase failure load, while 3 mL led to further significant improvement in the upper thoracic, lower thoracic and lumbar regions. Conclusion. Conventional, solid pedicle screws augmented with high-viscosity cement provided comparable screw stability in pull-out testing to that of sophisticated and more expensive fenestrated screws. In terms of cement volume, we recommend the use of at least 1 mL in the thoracic and 3 mL in the lumbar spine. Cite this article: C. I. Leichtle, A. Lorenz, S. Rothstock, J. Happel, F. Walter, T. Shiozawa, U. G. Leichtle. Pull-out strength of cemented solid versus fenestrated pedicle screws in osteoporotic vertebrae. Bone Joint Res 2016;5:419–426

We undertook a retrospective study investigating the accuracy and safety of percutaneous pedicle screws placed under fluoroscopic guidance in the lumbosacral junction and lumbar spine. The CT scans of patients were chosen from two centres: European patients from University Medical Center Hamburg-Eppendorf, Germany, and Asian patients from the University of Malaya, Malaysia. Screw perforations were classified into grades 0, 1, 2 and 3. A total of 880 percutaneous pedicle screws from 203 patients were analysed: 614 screws from 144 European patients and 266 screws from 59 Asian patients. The mean age of the patients was 58.8 years (16 to 91) and there were 103 men and 100 women. The total rate of perforation was 9.9% (87 screws) with 7.4% grade 1, 2.0% grade 2 and 0.5% grade 3 perforations. The rate of perforation in Europeans was 10.4% and in Asians was 8.6%, with no significant difference between the two (p = 0.42). The rate of perforation was the highest in S1 (19.4%) followed by L5 (14.9%). The accuracy and safety of percutaneous pedicle screw placement are comparable to those cited in the literature for the open method of pedicle screw placement. Greater caution must be taken during the insertion of L5 and S1 percutaneous pedicle screws owing to their more angulated pedicles, the anatomical variations in their vertebral bodies and the morphology of the spinal canal at this location. Cite this article: Bone Joint J 2015; 97-B:1111–17

Objectives. Many studies have investigated the kinematics of the lumbar spine and the morphological features of the lumbar discs. However, the segment-dependent immediate changes of the lumbar intervertebral space height during flexion-extension motion are still unclear. This study examined the changes of intervertebral space height during flexion-extension motion of lumbar specimens. Methods. First, we validated the accuracy and repeatability of a custom-made mechanical loading equipment set-up. Eight lumbar specimens underwent CT scanning in flexion, neural, and extension positions by using the equipment set-up. The changes in the disc height and distance between adjacent two pedicle screw entry points (DASEP) of the posterior approach at different lumbar levels (L3/4, L4/5 and L5/S1) were examined on three-dimensional lumbar models, which were reconstructed from the CT images. Results. All the vertebral motion segments (L3/4, L4/5 and L5/S1) had greater changes in disc height and DASEP from neutral to flexion than from neutral to extension. The change in anterior disc height gradually increased from upper to lower levels, from neutral to flexion. The changes in anterior and posterior disc heights were similar at the L4/5 level from neutral to extension, but the changes in anterior disc height were significantly greater than those in posterior disc height at the L3/4 and L5/S1 levels, from neutral to extension. Conclusions. The lumbar motion segment showed level-specific changes in disc height and DASEP. The data may be helpful in understanding the physiologic dynamic characteristics of the lumbar spine and in optimising the parameters of lumbar surgical instruments. Cite this article: M. Fu, Q. Ye, C. Jiang, L. Qian, D. Xu, Y. Wang, P. Sun, J. Ouyang. The segment-dependent changes in lumbar intervertebral space height during flexion-extension motion. Bone Joint Res 2017;6:245–252. DOI: 10.1302/2046-3758.64.BJR-2016-0245.R1

Aims. We reviewed 34 consecutive patients (18 female-16 male) with isthmic spondylolysis and grade I to II lumbosacral spondylolisthesis who underwent in situ posterolateral arthodesis between the L5 transverse processes and the sacral ala with the use of iliac crest autograft. Ten patients had an associated scoliosis which required surgical correction at a later stage only in two patients with idiopathic curves unrelated to the spondylolisthesis. . Methods. No patient underwent spinal decompression or instrumentation placement. Mean surgical time was 1.5 hours (1 to 1.8) and intra-operative blood loss 200 ml (150 to 340). There was one wound infection treated with antibiotics but no other complication. Radiological assessment included standing posteroanterior and lateral, Ferguson and lateral flexion/extension views, as well as CT scans. . Results. A solid posterolateral fusion was confirmed in all patients at mean latest follow-up of 4.7 years (3.4 to 9.8) beyond skeletal maturity into early adult life. Fusion of the isthmic lesion was documented in nine patients bilaterally and eight patients unilaterally. The poor fusion rate across the spondylolysis has not affected the excellent functional results of the procedure, which in our series depended on achieving a stable lumbosacral junction. . Conclusion. Quality of life assessment demonstrated significant improvement in all functional scores and high patient satisfaction with 28 patients returning to previous sports activities at an elite competitive level. Take home message: Posterolateral arthrodesis in situ with autologous iliac crest bone without instrumentation has achieved a solid fusion between the L5 transverse processes and the sacral ala in patients with grade I to II isthmic lumbosacral spondylolisthesis and this has produced excellent clinical outcomes and high patient satisfaction. Cite this article: Bone Joint J 2016;98-B:88–96

Aims. To clarify the asymmetrical ossification of the epiphyseal ring between the convex and concave sides in patients with adolescent idiopathic scoliosis (AIS). Patients and Methods. A total of 29 female patients (mean age, 14.4 years; 11 to 18) who underwent corrective surgery for AIS (Lenke type 1 or 2) were included in our study. In all, 349 vertebrae including 68 apical vertebrae and 87 end vertebrae in the main thoracic (MT) curve and thoracolumbar/lumbar (TL/L) curve were analysed. Coronal sections (anterior, middle and posterior) of the vertebral bodies were reconstructed from pre-operative CT scans (320-row detector; slice thickness, 0.5 mm) and the appearances of the ossification centre in the epiphyseal ring at four corners were evaluated in three groups; all vertebrae excluding end vertebrae, apical vertebrae and end vertebrae. The appearance rates of the ossification centre at the concave and convex sides were calculated and compared. Results. The appearance rates of the ossification centres in all vertebrae excluding end vertebrae and apical vertebrae were significantly lower on the concave side than on the convex side in both MT and TL/L curves irrespective of curve flexibility. There was no significant difference in the rate of appearance of the ossification centres on the concave or convex sides in end vertebrae. Conclusion. The asymmetric bony growth of vertebral body came into existence at both structural and non-structural curves, and was more apparent around the apical vertebrae. Evaluation of the ossification centre in the epiphyseal ring could be a measure of the effectiveness of brace treatment. Take home message: The ossification of the epiphyseal ring in patients with AIS was delayed or absent on the concave side particularly around the apical vertebrae. Cite this article: Bone Joint J 2016;98-B:666–71

Objectives. Pedicle-lengthening osteotomy is a novel surgery for lumbar spinal stenosis (LSS), which achieves substantial enlargement of the spinal canal by expansion of the bilateral pedicle osteotomy sites. Few studies have evaluated the impact of this new surgery on spinal canal volume (SCV) and neural foramen dimension (NFD) in three different types of LSS patients. Methods. CT scans were performed on 36 LSS patients (12 central canal stenosis (CCS), 12 lateral recess stenosis (LRS), and 12 foraminal stenosis (FS)) at L4-L5, and on 12 normal (control) subjects. Mimics 14.01 workstation was used to reconstruct 3D models of the L4-L5 vertebrae and discs. SCV and NFD were measured after 1 mm, 2 mm, 3 mm, 4 mm, or 5 mm pedicle-lengthening osteotomies at L4 and/or L5. One-way analysis of variance was used to examine between-group differences. Results. In the intact state, SVC and NFD were significantly larger in the control group compared with the LSS groups (P<0.05). After lengthening at L4, the percentage increase in SCV (per millimetre) was LRS>CCS>FS>Control. After lengthening at L5 and L4-L5, the percentage increase in SCV (per millimetre) was LRS>FS>CCS>Control. After lengthening at L4 and L4-L5, the percentage increase in NFD (per millimetre) was FS>CCS>LRS>Control. After lengthening at L5, the percentage increase in NFD (per millimetre) was CCS>LRS>control>FS. Conclusions. LRS patients are the most suitable candidates for treatment with pedicle-lengthening osteotomy. Lengthening L4 pedicles produced larger percentage increases in NFD than lengthening L5 pedicles (p < 0.05). Lengthening L4 pedicles may be the most effective option for relieving foraminal compression in LSS patients. Cite this article: P. Li, L. Qian, W. D. Wu, C. F. Wu, J. Ouyang. Impact of pedicle-lengthening osteotomy on spinal canal volume and neural foramen size in three types of lumbar spinal stenosis. Bone Joint Res 2016;5:239–246. DOI: 10.1302/2046-3758.56.2000469

Lateral oblique radiographs are considered important for the identification of spondylolytic lesions, but these projections will give a clear view only when the radiological beam is in the plane of the defect. We studied the variation in orientation of spondylolytic lesions on CT scans of 34 patients with 69 defects. There was a wide variation of angle: only 32% of defects were orientated within 15° of the 45° lateral oblique plane. Lateral oblique radiographs should not be considered as the definitive investigation for spondylolysis. We suggest that CT scans with reverse gantry angle are now more appropriate than oblique radiography for the assessment of spondylolysis. Variation in the angle of the defect may also need consideration when direct repair is being planned

We analysed the CT scans and radiographs of 76 vertebrae in 49 patients who underwent vertebroplasty for painful osteoporotic compression fractures. Leaks of cement were classified into three types: those via the basivertebral vein (type B), via the segmental vein (type S), and through a cortical defect (type C). More leaks were identified on CT scans than on radiographs by a factor of 1.5 (74/49). Most type-B (93%) and type-S (86%) leaks were missed or underestimated on a lateral radiograph which is usually the only view used during the injection of cement. Of the leaks into the spinal canal, only 7% (2/28) were correctly identified on radiographs. The areas on lateral radiographs where this type of leak may be observed were divided into four zones, and their diagnostic value in predicting a leak into the spinal canal was evaluated. The results showed that cement in the neural foramina had the highest positive predictive value (86%)

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.

Objectives. We performed a systematic review of the literature to determine the safety and efficacy of bone morphogenetic protein (BMP) compared with bone graft when used specifically for revision spinal fusion surgery secondary to pseudarthrosis. Methods. The MEDLINE, EMBASE and Cochrane Library databases were searched using defined search terms. The primary outcome measure was spinal fusion, assessed as success or failure in accordance with radiograph, MRI or CT scan review at 24-month follow-up. The secondary outcome measure was time to fusion. Results. A total of six studies (three prospective and three retrospective) reporting on the use of BMP2 met the inclusion criteria (203 patients). Of these, four provided a comparison of BMP2 and bone graft whereas the other two solely investigated the use of BMP2. The primary outcome was seen in 92.3% (108/117) of patients following surgery with BMP2. Although none of the studies showed superiority of BMP2 to bone graft for fusion, its use was associated with a statistically quicker time to achieving fusion. BMP2 did not appear to increase the risk of complication. Conclusion. The use of BMP2 is both safe and effective within the revision setting, ideally in cases where bone graft is unavailable or undesirable. Further research is required to define its optimum role. Cite this article: Mr P. Bodalia. Effectiveness and safety of recombinant human bone morphogenetic protein-2 for adults with lumbar spine pseudarthrosis following spinal fusion surgery: A systematic review. Bone Joint Res 2016;5:145–152. DOI: 10.1302/2046-3758.54.2000418

We investigated the safety and efficacy of treating osteoporotic vertebral compression fractures with an intravertebral cleft by balloon kyphoplasty. Our study included 27 patients who were treated in this way. The mean follow-up was 38.2 months (24 to 54). The anterior and middle heights of the vertebral body and the kyphotic angle were measured on standing lateral radiographs before surgery, one day after surgery, and at final follow-up. Leakage of cement was determined by CT scans. A visual analogue scale and the Oswestry disability index were chosen to evaluate pain and functional activity. Statistically significant improvements were found between the pre- and post-operative assessments (p < 0.05) but not between the post-operative and final follow-up assessments (p > 0.05). Asymptomatic leakage of cement into the paravertebral vein occurred in one patient, as did leakage into the intervertebral disc in another patient. We suggest that balloon kyphoplasty is a safe and effective minimally invasive procedure for the treatment of osteoporotic vertebral compression fractures with an intravertebral cleft

The presacral retroperitoneal approach for axial lumbar interbody fusion (presacral ALIF) is not widely reported, particularly with regard to the mid-term outcome. This prospective study describes the clinical outcomes, complications and rates of fusion at a follow-up of two years for 26 patients who underwent this minimally invasive technique along with further stabilisation using pedicle screws. The fusion was single-level at the L5-S1 spinal segment in 17 patients and two-level at L4–5 and L5-S1 in the other nine. The visual analogue scale for pain and Oswestry Disability Index scores were recorded pre-operatively and during the 24-month study period. The evaluation of fusion was by thin-cut CT scans at six and 12 months, and flexion-extension plain radiographs at six, 12 and 24 months. Significant reductions in pain and disability occurred as early as three weeks postoperatively and were maintained. Fusion was achieved in 22 of 24 patients (92%) at 12 months and in 23 patients (96%) at 24 months. One patient (4%) with a pseudarthrosis underwent successful revision by augmentation of the posterolateral fusion mass through a standard open midline approach. There were no severe adverse events associated with presacral ALIF, which in this series demonstrated clinical outcomes and fusion rates comparable with those of reports of other methods of interbody fusion

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: Bone Joint J 2014;96-B:541–7

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 heads were blocked by iliac bone: consequently, the interior oblique angle of the cadaveric specimens was less than that seen in the 3D digital images. . We suggest that CT scans should be carried out pre-operatively if this procedure is to be adopted in clinical practice. This will assist in determining the feasibility of the procedure and will provide accurate information to assist introduction of the screws. Cite this article: Bone Joint J 2013;95-B:977–82

The effect of rheumatoid arthritis on the anatomy of the cervical spine has not been clearly documented. We studied 129 female patients, 90 with rheumatoid arthritis and 39 with other pathologies (the control group). There were 21 patients in the control group with a diagnosis of cervical spondylotic myelopathy, and 18 with ossification of the posterior longitudinal ligament. All had plain lateral radiographs taken of the cervical spine as well as a reconstructed CT scan. The axial diameter of the width of the pedicle, the thickness of the lateral mass, the height of the isthmus and internal height were measured. The transverse diameter of the transverse foramen (d1) and that of the spinal canal (d2) were measured, and the ratio d1/d2 calculated. The width of the pedicles and the thickness of the lateral masses were significantly less in patients with rheumatoid arthritis than in those with other pathologies. The area of the transverse foramina in patients with rheumatoid arthritis was significantly greater than that in the other patients. The ratio of d1 to d2 was not significantly different. A high-riding vertebral artery was noted in 33.9% of the patients with rheumatoid arthritis and in 7.7% of those with other pathologies. This difference was statistically significant. In the rheumatoid group there was a significant correlation between isthmus height and vertical subluxation and between internal height and vertical subluxation

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 optimal procedure for the treatment of ossification of the posterior longitudinal ligament (OPLL) remains controversial. The aim of this study was to compare the outcome of anterior cervical ossified posterior longitudinal ligament en bloc resection (ACOE) with posterior laminectomy and fusion with bone graft and internal fixation (PTLF) for the surgical management of patients with this condition.

We have reviewed 1858 patients who had undergone a cervical laminoplasty and identified 43 (2.3%) who had developed a C5 palsy with a MMT (MRC) grade of 0 to 2 in the deltoid, with or without involvement of the biceps, but with no loss of muscular strength in any other muscles. The clinical features and radiological findings of patients with (group P; 43 patients) and without (group C; 100 patients) C5 palsy were compared. CT scanning of group P revealed a significant narrowing of the intervertebral foramen of C5 (p < 0.005) and a larger superior articular process (p < 0.05). On MRI, the posterior shift of the spinal cord at C4–5 was significantly greater in group P, than in group C (p < 0.01). This study is the first to correlate impairment of the C5 nerve root with a C5 palsy. It may be that early foraminotomy in susceptible individuals and the avoidance of tethering of the cord by excessive laminoplasty may prevent a post-operative palsy of the C5 nerve root

Aims

This systematic review aims to identify 3D predictors derived from biplanar reconstruction, and to describe current methods for improving curve prediction in patients with mild adolescent idiopathic scoliosis.

Aims

The aim of this study was to investigate the incidence and characteristics of instrumentation failure (IF) after total en bloc spondylectomy (TES), and to analyze risk factors for IF.

Aims

The aim of this study was to assess the accuracy of pedicle screw placement, as well as intraoperative factors, radiation exposure, and complication rates in adult patients with degenerative disorders of the thoracic and lumbar spines who have undergone robotic-navigated spinal surgery using a contemporary system.

Aims

This study addressed two questions: first, does surgical correction of an idiopathic scoliosis increase the volume of the rib cage, and second, is it possible to evaluate the change in lung function after corrective surgery for adolescent idiopathic scoliosis (AIS) using biplanar radiographs of the ribcage with 3D reconstruction?

Aims

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).

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.

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.

We examined the pathogenesis of Schmorl’s nodes, correlating the histological findings from 12 lumbar vertebrae with the corresponding conventional radiographs, tomographs, MR images and CT scans. The last revealed round, often multiple cystic lesions with indistinct sclerotic margins beneath the cartilaginous endplate. The appearances are similar to the typical CT changes of osteonecrosis. Histological examination of en-bloc slices through Schmorl’s nodes gave clear evidence of subchondral osteonecrosis. Beneath the cartilage endplate, we found fibrosis within the marrow cavities with the disappearance of fat cells. Osteocytes within bone trabeculae were either dead or had disappeared. We suggest that Schmorl’s nodes are the end result of ischaemic necrosis beneath the cartilaginous endplate and that herniation into the body of the vertebra is secondary

Lumbar spondylolysis can heal with conservative treatment, but few attempts have been made to identify factors which may affect union of the defects in the pars. We have evaluated, retrospectively, the effects of prognostic variables on bony union of pars defects in 134 young patients less than 18 years of age with 239 defects of the pars who had been treated conservatively. All patients were evaluated by CT scans when first seen and more than six months later at follow-up. The results showed that the spinal level and the stage of the defects were the predominant factors. The site of the defects in the pars, the presence or development of spondylolisthesis, the condition of the contralateral pars, the degree of lumbar lordosis and the degree of lumbar inclination all significantly affected union

Degenerative spondylolisthesis is four times more common in women than in men. Although this gender difference has long been recognised there has been no explanation for it. We have examined the radiographs and CT scans of 118 patients over the age of 55 years and of a control group under the age of 46 years. Our findings confirmed the presence of more sagittally-orientated facet joints in patients with degenerative spondylolisthesis but did not show that the gender difference can be explained by the morphology of the facet joint. Furthermore, we conclude that the increased angle of the facet joint is the result of arthritic remodelling and not the primary cause of degenerative spondylolisthesis. It is more likely to be due to loss of soft-tissue resilience with subsequent failure of the facet joints which are acting as the last restraints to subluxation

Computer-assisted frameless stereotactic image guidance allows precise preoperative planning and intraoperative localisation of the image. It has been developed and tested in the laboratory. We evaluated the efficacy, clinical results and complications of placement of a pedicle screw in the lumbar spine using this technique. A total of 62 patients (28 men, 34 women) had lumbar decompression and spinal fusion with segmental pedicle screws. Postoperative CT scans were taken of 35 patients to investigate the placement of 330 screws. None showed penetration of the medial or inferior wall of a pedicle. Registration was carried out 66 times. The number of fiducial points used on each registration averaged 5.8 (4 to 7) The mean registration error was 0.75 mm (0.32 to 1.72). This technique provides a safe and reliable guide for placement of transpedicular screws in the lumbar spine

The ratio of the sagittal diameter of the cervical canal to the corresponding diameter of the vertebral body has been described as a reliable means for assessing stenosis of the canal and detecting those at risk of cervical neuropraxia. The use of ratio techniques has the advantage of avoiding variation in magnification when direct measurements are made from plain radiographs. We examined the reliability of this method using plain lateral radiographs of unknown magnification and CT scans. We also assessed other possible ratios of anatomical measurements as a guide to the diameter of the canal. Our findings showed a poor correlation between the true diameter of the canal and the ratio of its sagittal diameter to that of the vertebral body. No other more reliable ratio was identified. The variability in anatomical morphology means that the use of ratios from anatomical measurements within the cervical spine is not reliable in determining the true diameter of the cervical canal

There is ambiguity concerning the nomenclature and classification of fractures of the ring of the second cervical vertebra (C2). Disruption of the pars interarticularis which defines true traumatic spondylolisthesis of C2, is often wrongly called a pedicle fracture. Our aim in this study was to assess the influence of asymmetry on the anatomical and functional outcome and to evaluate the criteria of instability established by Roy-Camille et al. We studied the plain radiographs and CT scans of 24 patients: 13 were judged to be asymmetrical, ten were considered unstable and 14 stable. Treatment was with a Minerva jacket in 15 fractures and by operation in nine. Surgery was undertaken in patients with severe C2 to C3 sprains. One patient with an unstable lesion refused operation and was treated conservatively with a poor radiological result. Our study showed that asymmetry of the fracture did not affect the outcomes of treatment and should not therefore influence decisions in treatment. The criteria of Roy-Camille seem to be reliable and useful. We prefer the posterior approach to the cervical spine, which allows both stabilisation of the fracture and correction of a local kyphosis

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The aim of this retrospective study was to compare the correction achieved using a convex pedicle screw technique and a low implant density achieved using periapical concave-sided screws and a high implant density. We hypothesized that there would be no difference in outcome between the two techniques.

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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.

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To evaluate the perioperative complications associated with total en bloc spondylectomy (TES) in patients with spinal tumours, based on the extent and level of tumour resection.

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The current pandemic caused by COVID-19 is the biggest challenge for national health systems for a century. While most medical resources are allocated to treat COVID-19 patients, several non-COVID-19 medical emergencies still need to be treated, including vertebral fractures and spinal cord compression. The aim of this paper is to report the early experience and an organizational protocol for emergency spinal surgery currently being used in a large metropolitan area by an integrated team of orthopaedic surgeons and neurosurgeons.

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The aim of this study was to systematically compare the safety and accuracy of robot-assisted (RA) technique with conventional freehand with/without fluoroscopy-assisted (CT) pedicle screw insertion for spine disease.

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The direct posterior approach with subperiosteal dissection of the paraspinal muscles from the vertebrae is considered to be the standard approach for the surgical treatment of adolescent idiopathic scoliosis (AIS). We investigated whether or not a minimally-invasive surgery (MIS) technique could offer improved results.

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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.

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The surgical treatment of tuberculosis (TB) of the spine consists of debridement and reconstruction of the anterior column. Loss of correction is the most significant challenge. Our aim was to report the outcome of single-stage posterior surgery using bone allografts in the management of this condition.

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We compared the clinical and radiological outcomes of using a polyetheretherketone cage with (TiPEEK) and without a titanium coating (PEEK) for instrumented transforaminal lumbar interbody fusion (TLIF).

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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).

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Identifying cervical spine injuries in confused or comatose patients with multiple injuries provides a diagnostic challenge. Our aim was to investigate the protocols which are used for the clearance of the cervical spine in these patients in English hospitals.

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Minimally invasive transforaminal lumbar interbody fusion (MITLIF) has been well validated in overweight and obese patients who are consequently subject to a higher radiation exposure. This prospective multicentre study aimed to investigate the efficacy of a novel lumbar localisation system for MITLIF in overweight patients.

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The primary aim of this study was to evaluate the performance and safety of magnetically controlled growth rods in the treatment of early onset scoliosis. Secondary aims were to evaluate the clinical outcome, the rate of further surgery, the rate of complications, and the durability of correction.