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.

Despite advances in treating acute spinal cord injury (SCI), measures to mitigate permanent neurological deficits in affected patients are limited. Augmentation of mean arterial blood pressure (MAP) to promote blood flow and oxygen delivery to the injured cord is one of the only currently available treatment options to potentially improve neurological outcomes after acute spinal cord injury (SCI). However, to optimize such hemodynamic management, clinicians require a method to measure and monitor the physiological effects of these MAP alterations within the injured cord in real-time. To address this unmet clinical need, we developed a series of miniaturized optical sensors and a monitoring system based on multi-wavelength near-infrared spectroscopy (MW-NIRS) technique for direct transdural measurement and continuous monitoring of spinal cord hemodynamics and oxygenation in real-time. We conducted a feasibility study in a porcine model of acute SCI. We also completed two separate animal studies to examine the function of the sensor and validity of collected data in an acute experiment and a seven-day post-injury survival experiment. In our first animal experiment, nine Yorkshire pigs underwent a weight-drop T10 vertebral level contusion-compression injury and received episodes of ventilatory hypoxia and alterations in MAP. Spinal cord hemodynamics and oxygenation were monitored throughout by a transdural NIRS sensor prototype, as well as an invasive intraparenchymal (IP) sensor as a comparison. In a second experiment, we studied six Yucatan miniature pigs that underwent a T10 injury. Spinal cord oxygenation and hemodynamics parameters were continuously monitored by an improved NIRS sensor over a long period. Episodes of MAP alteration and hypoxia were performed acutely after injury and at two- and seven-days post-injury to simulate the types of hemodynamic changes patients experience after an acute SCI. All NIRS data were collected in real-time, recorded and analyzed in comparison with IP measures. Noninvasive NIRS parameters of tissue oxygenation were highly correlated with invasive IP measures of tissue oxygenation in both studies. In particular, during periods of hypoxia and MAP alterations, changes of NIRS-derived spinal cord tissue oxygenation percentage were significant and corresponded well with the changes in spinal cord oxygen partial pressures measured by the IP sensors (p < 0.05). Our studies indicate that a novel optical biosensor developed by our team can monitor real-time changes in spinal cord hemodynamics and oxygenation over the first seven days post-injury and can detect local tissue changes that are reflective of systemic hemodynamic changes. Our implantable spinal cord NIRS sensor is intended to help clinicians by providing real-time information about the effects of hemodynamic management on the injured spinal cord. Hence, our novel NIRS system has the near-term potential to impact clinical care and improve neurologic outcomes in acute SCI. To translate our studies from bench to bedside, we have developed an advanced clinical NIRS sensor that is ready to be implanted in the first cohort of acute SCI patients in 2022

Lumbar fusion remains the gold standard for the treatment of discogenic back pain. Total disc replacement has fallen out of favor in many institutions. Other motion preservation alternatives, such as nucleus replacement, have had limited success and none are commercially available at this time. Two prospective, nonrandomized multicenter studies of lumbar disc nucleus replacement using the PerQdisc 2.0 nucleus replacement device in patients with lumbar discogenic back pain. Early clinical results are presented. A total of 16 patients from 4 international sites (Germany, Paraguay, Canada and Belgium) were enrolled in the trial between May 2019 and February 2021. Data collection points include baseline and postoperatively at 1, 2, 6, and 12 months. Clinical outcome measures were obtained from the Visual Analog Scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), SF-12V2, Analgesic Score (AS), and radiographic assessments. Prospectively gathered data on patient reported outcomes, neurological outcome, surgical results, radiological analysis, and any adverse events. 16 patients had successful implantation of the device. There have been no expulsions of the device. Early postoperative results are available in 13/16 patients at 6 months and 11/16 patients at 12 months. There have been 4 (25%) revision surgeries 3–12 months post implantation between the two trials. 12 of 13 (92%) patients had Minimal Clinically Important Difference (MCID) in ODI at 6 months and 10 of 11 (91%) at 12 months. Mean decrease in ODI from baseline to 12 months was 44.8. At 12 months 8 (73%) patients are not taking pain medication, 1 (9%) patient is taking a narcotic for pain management. 73% of patients are working without restrictions at 12 months post implant. Early clinical and technical results are encouraging. Long term follow up is essential and is forthcoming. Additional patient recruitment and data points are ongoing. FDA/Drug Status Investigational/Not approved

Introduction. Evidence suggests that intra-operative spinal cord monitoring is sensitive and specific for detecting potential neurological injury. However, little is known about surgeons' responses to trace changes and the resultant neurological outcome. Objective. To examine the role of intra-operative somatosensory evoked potential (SSEP) monitoring in the prevention of neurological injury, specifically sensitivity and specificity, and whether the abnormalities were reversible. Methods. 2953 consecutive complex spine operations (male 36% female 64%, median age 25yrs) prospectively performed using spinal cord monitoring at a single institution (2005–2009). All traces and neurophysiological events were prospectively recorded by the neurophysiology technician. All patients with a significant neurophysiology event were examined clinically by a neurologist, separate from the spinal surgery team. Significant trace abnormality was defined as a decrease in signal amplitude of 50% or a 10% increase in latency. Timing of trace abnormality, surgeon's response and prospective neurological outcome were recorded. Sensitivity, specificity, positive/negative predictive value were calculated. A Chi-squared test was performed to assess the impact of intervention on neurological outcome (p < 0.05). Results. 2953 operations involving SSEP monitoring were performed and 106 recorded a significant trace abnormality. This most often occurred during instrumentation and the most common reaction was adjustment of metalwork. SSEP monitoring had a sensitivity of 100%, specificity 97.3%, PPV 24%, NPV 100%. There were 79 false positives and no false negatives in this series. Chi-squared test was not significant (p=0.18) suggesting that intervention might not affect neurological outcome in this cohort. Conclusions. Triggering events are uncommon and the development of a persistent neurological deficit is rare with an incidence of 0.85% in this series of 2953 operations. In the majority of cases detection of a monitoring abnormality prompts a corrective reaction by the surgeon. Of those with an abnormal trace 76% were neurologically normal at follow up

National Institute of Clinical Excellence guidelines on Metastatic Spinal Cord Compression recommend urgent consideration of patients with spinal metastases and imaging evidence of structural spinal failure with spinal instability for surgery to stabilise the spine and prevent Metastatic Spinal Cord Compression. We aimed to compare neurological outcomes of patients managed operatively and non-operatively. Prospective collection of 397 patients' data over a 4-year period. Males represented 59.2% of patients. Median age was 69 years. Non-operative intervention in 62.2% of patients. Prostate, lung, Breast, Myeloma, Renal Cell Carcinoma and Lymphoma accounted for over 75% of all primary tumours (n=305). Median Length of hospital stay was longer in the operative group of 15 days compared to 10 days in the non-operative group (p<0.0001). Patients who were ambulating on presentation maintained their ambulation in 70.2% of cases in the operative group compared to 90.9% in the non-operative group (p<0.0001). However, upon discharge 41% of patients managed operatively were ambulatory compared to the non-operative group rate of 36.5% (p<0.0001). In Prostate, Breast, Myeloma, RCC and Lymphoma 100% of patients managed non-operatively maintained ambulation. Lung primaries managed operatively had an 80% chance of maintaining ambulation compared to 76.9% in the non-operative group (p<0.05). A higher proportion of patients managed non-operatively maintained ambulation than those managed operatively. With operative intervention, more patients regained ambulatory status. Whilst we have mainly focused on ambulatory status in this paper there are other factors to consider including pain relief and spinal stability which may be an indication for surgical intervention

Objective-Study Design: Recognizing the value of intraoperative SEP monitoring in scoliosis and other spinal surgery, we applied prospectively continuous SEP recording during reconstructive procedures in 82 patients who sustained 20 cervical, 8 thoracic, 6 thoraco-lumbar, and 48 lumbar vertebral fractures or fractures-dislocations to investigate its efficacy in spinal trauma. Material: Seventy-one patients underwent single anterior or posterior operations, and 11 combined anterior-posterior procedures. Forty patients had incomplete injuries, and 42 had no preoperative neurological deficit. SEP trace amplitude at insertion of electrode was considered as the baseline value, and was compared to the lowest intraoperative signal amplitude and the amplitude at completion of operation. Results: Fifty-nine patients had a depression in wave amplitude of more than 25% during surgery; in 25 patients the trace fell by more than 50%, and in 7 cases a more than 75% diminution was recorded. A loss of 50% in SEP signal amplitude showed 67% sensitivity, and 71% specificity in predicting neurologic outcome. Patients with a fall in SEP amplitude of more than 50% that did not recover at completion of the surgical procedure demonstrated an increased risk of neurological compromise (p< .01). Increasing trace deterioration threshold from 50 to 60% improved specificity to 81% without compromising sensitivity. There was also 100% correlation between the side of the amplitude drop and the side of neurological loss in the trunk or limb (p< .001). A total number of 22 patients had improved SEP recordings before skin closure; 19 of these patients demonstrated an improved neurologic function after the operative procedure. In these 19 patients a positive statistical association could be documented between the signal changes and the neurological outcome (p< .05). Nevertheless, 2 of the patients with up to 20% improvement in the trace amplitude compared to the original control measurement presented deterioration in their neurological picture in the postoperative period. In 17 patients the SEP waveform amplitude was unchanged at conclusion of the operation; in those cases the neurological functional level post-surgery was equally unaltered. No significant difference was obtained when comparing the systolic blood pressures or the core temperatures at skin closure between the different outcome groups (p> .05). A loss of more than 50% in SEP amplitude occurred with significantly increased incidence during the anterior compared to the posterior spinal procedures (p< .001). More than 20% recovery in signal amplitude at conclusion of the procedure in patients with incomplete injuries was correlated with favorable neurological function. Conclusions: Persistent intraoperative decrement in SEP amplitude and poor restitution at completion of surgery increase the risk for postoperative neurologic compromise. In this series, continuous intraoperative SEP monitoring appeared to be adequately reproducible, sufficiently reliable, and therefore a practical tool in monitoring operative procedures for spinal trauma. Even though compared to deformity surgery the method is less sensitive and specific, it may help reduce the incidence of devastating neurologic injury during the operation on an already compromised neural cord, and can provide good prediction in terms of postoperative neurological outcome. Thus, it could be considered a useful surgical adjunct in the management of patients with spinal trauma

To assess whether the timing of surgery is an important factor in neurological outcome in patients with MSCC. Retrospective review. All patients with MSCC presenting to our unit were included in this study from October 2003 to December 2009. Patients were divided into three groups - those who underwent surgery within 24 hours (Group 1), those 24 hours to 48 hours (Group 2) and those greater than 48 hours (Group 3). Neurological outcome (improvement in Frankel score), complication rate and survival were assessed in all groups. A total of 109 patients with MSCC were operated on in our unit during this time. Mean age of patients was 61 years (range 7 - 86). The number that had at least one grade of Frankel improvement was 21 /37 (57%) in group 1; 11/17 (65%) in group 2 and 20/49 (41%) in group 3, p=0.03. When patients treated less than 24 hours were compared with those greater than 24 hours, the Frankel grade improvement approached significance (p=0.05). When we compared those who had surgery within 48 hours and those greater than 48 hours, the Frankel grade improvement was highly significant (p=0.009). There was no difference in survival or complications between the groups. Our results suggest that early surgical treatment in patients with MSCC gives a better neurological outcome but has no influence on survival or complication rates

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).

Introduction. Somatosensory evoked potential (SSEP) monitoring allows for assessment of the spinal cord and susceptible structures during complex spinal surgery. It is well validated for the detection of potential neurological injury but little is known of surgeon's responses to an abnormal trace and its effect on neurological outcome. We aimed to investigate this in spinal deformity patients who are particularly vulnerable during their corrective surgery. Methods. Our institutional neurophysiology database was analysed between 1. st. October 2005 and 31. st. March 2010. Monitoring was performed by a team of trained neurophysiology technicians who were separate from the surgical team. A significant trace was defined as a 50% reduction in trace amplitude or a 10% increase in signal latency. Patients suffering a significant trace event were examined post-operatively by a Consultant Neurologist who was separate from the surgical team. Results. 2386 consecutive operations (F:1719, M:667 median age 16 yrs) were performed in the time period and 72 operations reported a significant trace event (‘red alert’). From these cases 47 (65%) had a clearly documented intervention by the surgeon and 7 patients overall suffered a lasting neurological deficit (0.3%). The most common timing events were during instrumentation (50%) and during correction/distraction (16%). Most common responses were optimisation of patient/monitoring set-up (23%) and adjustment of metalwork (22%). There were 18 wake-up tests performed. We found SSEP monitoring to have a sensitivity of 100%, specificity 97.4%, positive predictive value 14% and negative predictive value 100%. A Chi-square test (p=0.016) was significant suggesting intervention had a beneficial effect on neurological outcome. Conclusion. We would advocate the use of SSEP monitoring in all patients undergoing spinal deformity surgery. These patients tend to be young, neurologically intact pre-operatively and are particularly vulnerable to the large corrective forces their surgery requires

Aim: To determine whether timing of intervention affects neurological outcome after spinal cord injury resulting from rugby cervical facet dislocations. Methods: An observational study on 57 rugby players who were admitted to a Spinal Cord Injuries Unit from 1988 to 2000 with cervical spine facet dislocations. Experienced medical officers, an orthopaedic specialist and physiotherapists determined the admission and discharge Frankel grades (A to E). The time was recorded from the actual injury to successful reduction in hours. The usual method of reduction was by Rapid Incremental Traction on an Awake Patient. Statistical analysis was performed using parametric and non-parametric tests (Mann Whitney). Results: 14 patients were treated within 4 hours of injury and 43 were treated after 4 hours. The median Frankel gain for patients reduced within 4 hours was 5 but only 2 for those reduced after 4 hours (p= 0.0002). Conclusion: Time from injury to intervention does significantly affect neurological outcome in a homogenous group of spinal cord injuries in fit young males as a result of low velocity trauma mechanisms. Spinal cord injuries secondary to cervical facet dislocations in these patients should be regarded as an absolute emergency

Objective: To study the long term operative and non-operative outcome in patients with diastematomyelia (DM). Design: A prospectively acquired database of all spinal patients seen jointly by the senior authors (JKW, JLF), was searched for patients with DM. Their notes and the database were then reviewed. Subjects: Thirty-six patients were identified; twenty-one (58%) had associated scoliosis. There were 60 associated abnormalities in the 36 patients, most common being ten (27%) with leg length inequality. Twelve patients (33%) had no radiological bony abnormality. Twenty-four (66%) had neurosurgery, eleven (31%) untethering of filum alone and eleven (31%) with removal of a spur and closure of the DM as well. Nineteen (53%) underwent some sort of neuraxial shortening scoliosis correction/surgery. Twenty-eight (78%) were deemed to have a normal/independent neurological outcome, seventeen (61%) having neurosurgery and twelve (43%) scoliosis surgery. Conclusions: Patients with DM have been followed up for many years. Good neurological outcomes can be anticipated in cases with untethering and with scoliosis correction alone. This series raises the question as to whether any unthethering procedure is necessary in these cases when neuraxial shortening is carried out for scoliosis cases

Introduction: Somatosensory evoked potentials are monitored during the surgical treatment of spinal disorders to reduce the risk of cord injury. Whilst studies have examined its role in patients undergoing correction of idiopathic and neuromuscular scoliotic curves, its effectiveness in patients undergoing operative treatment for spinal injury is less certain. Methods and Results: We reviewed the medical records of patients who underwent surgery for spinal trauma. between 1995 and 2000. There were 82 patients with adequate data for analysis who underwent 83 spinal reconstructive procedures. We recorded the age at injury, diagnosis, time of operation, levels instrumented, systolic and diastolic blood pressures and surgical approach. The intraoperative somatosensory evoked potential (SSEP) traces were examined. The SSEP at insertion of electrode was taken as the control level. The highest and lowest intraoperative somatosensory evoked potentials and SSEP at closure were noted and expressed as a percentage of the control value. Forty patients (48%) had a pre-operative neurological deficit. Neurological deterioration occurred postoperatively in three patients. Eighty-three traces from 82 patients were available for analysis. Fifty-seven patients had a fall in trace amplitude by more than 25% of the control, 25 by more than 50% and eight by more than 75%. With an SSEP amplitude loss of 60%, both sensitivity and specificity for the prediction of post-operative neurological injury were optimised at 67 and 81% respectively, with one false negative result. SSEP rise at completion of spinal reconstruction and highest intraoperative SSEP rise was compared with neurological outcome in the 40 patients with abnormal pre-operative neurology. Neurology improved in all patients in this group who had a trace amplitude more than 60% above the control value at end of operation. None had neurological deterioration. There was no correlation between intraoperative SSEP rise and neurological outcome. Conclusion: Loss of trace amplitude more than 50% is common during spinal reconstructive surgery after trauma, however a 60% threshold for SSEP fall improves specificity by reducing the rate of false positive results. A trace amplitude 60% above the control value at completion of operation is specific but not sensitive for postoperative neurological improvement

Back ground:. The aim of this study is to evaluate the long-term outcome after posterior spinal stabilization surgery for the management of de novo non-tuberculous bacterial spinal infection. Method and Result:. Patients presenting to a single tertiary referral spinal centre between August 2011 and June 2014 were included in the study. 21 patients with nontuberculous bacterial infection were identified and included in the study. All patients were managed surgically with posterior stabilisation, with or without neural decompression, without debridement of the infected tissue. Neurological state was assessed using the frankel grading system before and after urgery. Long-term follow-up data was collected using SpineTango COMI questionnaires and Euro Qol EQ-5D system with a mean follow-up duration of 20 months postoperatively. The mean improvement in neurological deficits was 0.92 Frankel grade (range 0–4). At final followup, at a mean of 20 months, mean COMI score was 4.59, average VAS for back pain was 4.28. These symptoms were having no effect or only minor effect on the work or usual activities in 52%. 38% of patients reported a good quality of life. The average EQ-5D value was 0.569. There were no problems with mobility in 44% of patients. In 72% there were no problems with self-care. Conclusion:. Our study has shown that posterior surgery for the management of bacterial, nontuberculous spinal infection can improve neurological outcome in approximately half of the patients. However, at long term followup, only around 50% of patients was able to return their pre-morbid work or usual activities

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.

Aim:. Recent guidelines have been published by the Association of Neurophysiological Scientists / British Society for Clinical Neurophysiology (ANS/BSCN) regarding the use of intra-operative neurophysiological monitoring (IOM) during spinal deformity procedures. We present our unit's experience with IOM and the compliance with national guidelines. Method:. All patients undergoing intra-operative spinal cord monitoring during adult and paediatric spinal deformity surgery between Jan 2009 and Dec 2012 were prospectively followed. The use of somatosensory-evoked potentials (SSEPs) and motor-evoked potentials (MEPs) was recorded and monitoring outcomes were compared to post-operative clinical neurological outcomes. Compliance with the national ANS/BSCN guidelines was assessed. Results:. 333 patients were included in this study. IOM was successful in 312 patients (94%), with both MEPs and SSEPs obtained in 282 patients (85%). SEPs were achieved in 91% and MEPs in 87%. Aetiology was idiopathic in 199 cases, 53 neuromuscular, 28 degenerative, 16 congenital, 16 other. Nine patients had changes in IOM related to surgical activity; six had MEP changes only, three had MEPs and SSEPs changes. All but one of these changes returned to baseline following surgical action; the one remaining patient had a temporary postoperative neurological deficit. One patient had a post-operative single radiculopathy requiring surgical exploration, without change in initial IOM. Final IOM findings demonstrated a positive predictive value (PPV) of 1 and a negative predictive value (NPV) of 0.996. Discussion:. IOM is essential during spinal deformity surgery and, using MEPs, has a high PPV and NPV. Our unit meets guidelines for MEP use and frequently meets guidelines for SSEP use. Conflict Of Interest Statement: No conflict of interest

The revised Tokuhashi score has been widely used to evaluate indications for surgery and predict survival in patients with metastatic spinal disease. Our objective was to determine whether the score accurately predicted survival in those with MSCC. Retrospective analysis. All patients with MSCC presenting to our unit were included in this study from October 2003 to December 2009. Patients were divided into three groups – Tokuhashi score 0 – 8, 9 – 11 and 12 -15. Neurological outcome and survival. A total of 109 patients with MSCC were managed in our unit during this time. Mean age of patients was 61 years (range 7 - 86). Mean and median survival was 350 (5-2256) and 93 days in the 0-8 group, 439 (8-1902) and 229 days in the 9-11 group, and 922 (6-222) and 875 days in the 12-15 group; p = 0.01. All patients underwent decompression and stabilisation surgery. The rate of consistency between the prognostic score and actual survival was 64% (0-8), 64% (9-11) and 69% (12-15). Overall the consistency was 66%. There was no difference in neurological outcome between the 3 groups. There was a significant difference in the mean survival between groups. There was a moderate consistency between predicted and actual survival in this group of patients who all had cord compression. All patients had undergone some form of decompression and stabilisation surgery regardless of the overall revised Tokuhashi score

Background. There is minimal published data regarding the long-term functional outcome in pyogenic spinal infection. Previous studies have used heterogeneous, unreliable and non-validated measure instruments, or neurological outcome alone, yielding data that is difficult to interpret. We aim to assess long-term adverse outcome using standardised measures, Oswestry disability index (ODI) and MOS short form-36 (SF-36). Methods. All cases of pyogenic spinal infection presenting to a single institution managed operatively and non-operatively from 1994-2004 were retrospectively identified. Follow-up was by clinical review and standardised questionnaires. Inclusion in each case was on the basis of consistent clinical, imaging and microbiology criteria. Results. Twenty-nine cases of pyogenic spinal infection were identified. Twenty-eight percent were managed operatively and 72% with antibiotic therapy alone. Nineteen patients (66%) had an adverse outcome at a median follow-up of 61 months, despite only 5 patients (17%) having persistent neurological deficit. A significant difference in SF-36 PF (physical function) scores was observed between patients with adverse outcome and patients who recovered (p=0.003). SF-36 scores of all patients, regardless of management or outcome, failed to reach those of a normative population. A strong correlation was observed between ODI and SF-36 PF scores (rho=0.61, p<0.05). Seventeen percent (n=5) of admissions resulted in acute sepsis-related death. Subgroup analysis revealed delay in diagnosis of spinal infection (p=0.025) and neurological impairment at diagnosis (p<0.001) to be significant predictors of neurological deficit at follow-up. Previous spinal surgery was associated with adverse outcome in patients requiring readmission within 1 year of hospital discharge following first spinal infection (p=0.018). No independent predictors of adverse outcome, persistent neurological impairment, readmission within 1 year or acute death were identified by logistical regression analysis. Conclusions. High rates of adverse outcome detected using SF-36 and ODI suggest under-reporting of poor outcome when ASIA score alone is used to qualify outcome

The optimal management of patients with the diagnosis of a spinal epidural abscess (SEA) remains controversial. The purpose of this study was to describe the clinical characteristics of patients presenting with spontaneous SEA and to correlate presentation and treatment with clinical and neurological outcome. A retrospective review of the medical records and radiology of patients with a diagnosis of SEA, treated between September 2003 and December 2010, at a tertiary referral hospital was performed. A total of 46 patients were identified including 27 males and 19 females. Mean age was 61 years (range, 30 – 86 years). At presentation, all patients had axial pain and 67% had a neurological deficit, out of which one third had paraplegia or quadriplegia. 32% patients were febrile. Diabetes was the most common risk factor (30%) followed by malignancy (17%), intravenous drug use (6%) and alcoholism (2%). Organisms were cultured in 44 patients with Methicillin Sensitive Staphylococcus Aureus most common (68%), followed by Methicillin Resistant Staphylococcus Aureus (14%). The epidural abscess was located in the lumbar spine in 24 patients, thoracic spine in 11 patients and cervical spine in 11 patients. 61% of patients had a concurrent source of septic focus on presentation, including psoas abscess (24%), facet joint septic arthritis (15%), pneumonia (11%), infective endocarditis (7%) and urosepsis (4%). 26% of patients were treated non-operatively, with computed tomography-guided aspiration and/or intravenous antibiotics based on cultures, whereas 74% underwent surgical decompression with or without fusion in combination with antibiotics. The mean inpatient hospital stay was 42 days (range, 2 – 742 days) and 34% of patients required an average of 40 days of Intensive Care Unit admission. At time discharge from hospital, of the patients managed nonoperatively, 33% had improved neurological function, 17% had worsened neurological function, 17% died and data was unavailable in 33%. Of the patients treated with surgery, 74% had improved neurological function, 6% remained unchanged, 6% had worsened neurologic function, 6% died and data was unavailable in 9% at time of discharge. SEA remains a severe condition associated with multiple septic foci and significant morbidity. Surgical decompression combined with antibiotics is associated with superior neurologic recovery compared with non-operative management, however a significant proportion of patients still deteriorate or die. Early diagnosis and management may prevent or reduce permanent neurologic deficit

Aim: Of Calveston (USA) and Crete (HELLAS). We studied immediate and long-term outcome of 50 patients who underwent subaxial lateral mass fixation of the cervical spine between January 1997 and March 2001. Patients and Methods: Intraopeartive fluoroscopy and somatosensory evoked potential monitoring were employed in all patients. Immediate postoperative CT scans were performed to determine screw trajectory and placement. Follow up ranged from 1 to 5 years. Results: Postoperative CT scans showed that 113 of 210 screws (54%) had unicorticate and 46% had bicorticate purchase. Forty-five screws (31 %) had suboptimal trajectory, but only 7 of these screws minimally penetrated the foramen transversarium without resultant vascular or neurological sequelae. The overall fusion success rate in our series was 90%, while pseudoarthrosis occurred in 5 patients (10%), with screw breakage in 1 patient (2%). Two of these patients had bone graft supplementation and in other 2 patients was done anterior fusion. Conclusions: Results of this study show that the recommended drilling technique and trajectory (15–25 degrees postal to the sagital plane, 20–30 degrees lateral I the axial plane), supplemented bone grafting and intraoperative SEP monitoring are all associated to good screw placement, fusion and neurological outcome and are recommended for all lateral mass fusion procedures

Objective: To assess the correlation between the Denis classification and clinical outcomes. Subjects and Design: We performed a retrospective study of 87 patients with spinal injuries in the thoracolumbar region. All patients were admitted to the Oswestry Spinal injuries unit between Jan 1990 and December 1998. Following a review of their notes, CT scans and radiographs, we attempted to classify their injuries according to the Denis (3 column) Classification of spinal injuries. Outcome Measures: The patients were assessed both at the time of presentation and on subsequent follow up. Neurological function was assessed using the Frankel classification. Results: The results of the study show that the correlation between Denis classification and clinical outcome is poor. In addition, the relative proportions of the two most common Major Injury types described by Denis were reversed in our study with Burst fractures forming the majority of injuries. This difference in out come was attributed primarily to the increased use of CT scanning in our study. It appears that Denis misdiagnosed a significant number of burst (two column) fractures as compression (anterior column) fractures. Conclusions: Our findings showed no correlation between the degree of instability and the number of columns disrupted. We believe that only 3 column fracture dislocations are fundamentally unstable. In addition, our results support the practise of treating vertebral fractures by conservative means with no apparent correlation between treatment modality and neurological outcome at long term follow up