Aims. Scoliosis is a lateral curvature of the spine with associated rotation, often causing distress due to appearance. For some curves, there is good evidence to support the use of a spinal brace, worn for 20 to 24 hours a day to minimize the curve, making it as straight as possible during growth, preventing progression. Compliance can be poor due to appearance and comfort. A night-time brace, worn for eight to 12 hours, can achieve higher levels of curve correction while patients are supine, and could be preferable for patients, but evidence of efficacy is limited. This is the protocol for a randomized controlled trial of ‘full-time bracing’ versus ‘night-time bracing’ in adolescent idiopathic scoliosis (AIS). Methods. UK paediatric spine clinics will recruit 780 participants aged ten to 15 years-old with AIS, Risser stage 0, 1, or 2, and curve size (Cobb angle) 20° to 40° with apex at or below T7. Patients are randomly allocated 1:1, to either full-time or night-time bracing. A qualitative sub-study will explore communication and experiences of families in terms of bracing and research. Patient and Public Involvement & Engagement informed study design and will assist with aspects of trial delivery and dissemination. Discussion. The primary outcome is ‘treatment failure’ (Cobb angle progression to 50° or more before skeletal maturity); skeletal maturity is at Risser stage 4 in females and 5 in males, or ‘treatment success’ (Cobb angle less than 50° at skeletal maturity). The comparison is on a non-inferiority basis (non-inferiority margin 11%). Participants are followed up every six months while in brace, and at one and two years after skeletal maturity. Secondary outcomes include the Scoliosis Research Society 22 questionnaire and measures of quality of life, psychological effects of bracing, adherence, anxiety and depression, sleep, satisfaction, and educational attainment. All data will be collected through the British Spine Registry. Cite this article: Bone Jt Open 2023;4(11):873–880

There is a need for non-radiographic, objective outcome measures for children with Adolescent Idiopathic Scoliosis (AIS). Standing balance and stability is altered in children with AIS. The Margin of Stability (MoS) has been used to compare gait stability in clinical populations. Our objective was to compare the MoS in anterior-posterior (MoS. AP. ) and mediolateral (MoS. ML. ) directions in girls with AIS to Controls. Girls with AIS and healthy girls walked at three speeds on an instrumented treadmill wearing retroreflective markers, surrounded by motion capture cameras. The MoS. AP/ML. was calculated at left and right heel strike. Data was processed in Visual 3D. A two-way ANOVA was used to compare MoS. AP/ML. between group, speed and the interaction between group and speed. Pearson's correlation coefficient was used to compare the MoS to Cobb angle. Statistical significance was accepted when p > 0.05. A priori power analysis suggested 12 participants per group. Three Cases and four Controls were recruited. Girls with AIS all had right-sided main thoracic curves (Lenke type 1a, 61.3° ± 10.0°). MoS. AP. was significantly bigger for Cases compared to Controls on the left (p=0.038) and right foot (p=0.041). There was no significant difference between Cases and Controls for MoS. ML. , but there was a visual trend for a smaller MoS. ML. in Cases. There was no significant difference for speed or the interaction between group and speed for MoS. AP. or MoS. ML. In Cases, MoS. AP. increased with increasing Cobb angle on the left (r. 2. =0.687, p=0.054) and right (r. 2. =0.634, p=0.067) and MoS. ML. decreased with increasing Cobb angle on the left (r. 2. =-0.912, p=0.002). Further subjects are being recruited. Girls with Lenke type 1a AIS are more stable in the AP direction and less stable in the ML direction than Controls during treadmill walking. AP stability increases and ML stability decreases with increasing Cobb angle. This research suggests that the MoS could be used as an outcome measure for children with AIS. Continued work is required to increase the power of this study. Further work could consider these changes during walking overground, measuring an MoS or MoS-like measure using a wearable device, and in different curve types

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.

The footplate in the current available TDR is flat without any allowance for endplate concavity in the sagittal plane. To assess the morphology of the endplates of the lower lumbosacral in the sagittal plane, and to identify the frequently occurring shape patterns of the end plates at each level. Retrospective Study. 200 consecutive magnetic reasonance imaging (MRI) scans of patients between the age of 30 and 60 years were analysed. In each endplate, the anteroposterior width, the height of concavity of the endplate, and the distance of the summit from the anterior vertebral body margin were noted. The shape of the endplate was noted as oblong (o) if the curve was uniform starting from the anterior margin and finishing at the posterior margin, eccentric (e) if the curve started after a flat portion at the anterior border and then curving backwards, and flat (f) if there is no curve in the sagittal plane. The shape of the end plate is mostly oblong at L3 IEP(59%), equally distributed between oblong and eccentric at L4 SEP (o=43.5%, e=46.5%), eccentric at L4 IEP (e=62.5%), eccentric at L5 SEP (e = 59.0%), eccentric at L5 IEP (e=94.0%), and flat at S1 SEP (f=82.5%). As there is a difference in the shape of the endplate at each level and they are not uniform, there is a need to focus on the sagittal shape of the footplate to avoid subsidence and mismatch of the footplate in cases of endplate concavity

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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).

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Lumbar spinal stenosis (LSS) is a common skeletal system disease that has been partly attributed to genetic variation. However, the correlation between genetic variation and pathological changes in LSS is insufficient, and it is difficult to provide a reference for the early diagnosis and treatment of the disease.

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Surgical approaches to cervical ossification of the posterior longitudinal ligament (OPLL) remain controversial. The purpose of the present study was to analyze and compare the long-term neurological recovery following anterior decompression with fusion (ADF) and posterior laminectomy and fusion with bone graft and internal fixation (PLF) based on > ten-year follow-up outcomes in a single centre.

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The number of patients undergoing surgery for degenerative cervical radiculopathy has increased. In many countries, public hospitals have limited capacity. This has resulted in long waiting times for elective treatment and a need for supplementary private healthcare. It is uncertain whether the management of patients and the outcome of treatment are equivalent in public and private hospitals. The aim of this study was to compare the management and patient-reported outcomes among patients who underwent surgery for degenerative cervical radiculopathy in public and private hospitals in Norway, and to assess whether the effectiveness of the treatment was equivalent.

Objectives. To employ a simple and fast method to evaluate those patients with neurological deficits and misplaced screws in relatively safe lumbosacral spine, and to determine if it is necessary to undertake revision surgery. Methods. A total of 316 patients were treated by fixation of lumbar and lumbosacral transpedicle screws at our institution from January 2011 to December 2012. We designed the criteria for post-operative revision scores of pedicle screw malpositioning (PRSPSM) in the lumbosacral canal. We recommend the revision of the misplaced pedicle screw in patients with PRSPSM = 5′ as early as possible. However, patients with PRSPSM < 5′ need to follow the next consecutive assessment procedures. A total of 15 patients were included according to at least three-stage follow-up. Results. Five patients with neurological complications (PRSPSM = 5′) underwent revision surgery at an early stage. The other ten patients with PRSPSM < 5′ were treated by conservative methods for seven days. At three-month follow-up, only one patient showed delayed onset of neurological complications (PRSPSM 7′) while refusing revision. Seven months later, PRSPSM decreased to 3′ with complete rehabilitation. Conclusions. This study highlights the significance of consecutively dynamic assessments of PRSPSMs, which are unlike previous implementations based on purely anatomical assessment or early onset of neurological deficits.and also confirms our hypothesis that patients with early neurological complications may not need revision procedures in the relatively broad margin of the lumbosacral canal. Cite this article: X-J. Lin. Treatment strategies for early neurological deficits related to malpositioned pedicle screws in the lumbosacral canal: A pilot study. Bone Joint Res 2016;5:46–51

The skeleton is the most common site to be affected by metastatic cancer. The place of surgical treatment and of different techniques of reconstruction has not been clearly defined. We have studied the rate of survival of 94 patients and the results of the surgical treatment of 91 metastases of the limbs and pelvis, and 18 of the spine. Variables included the different primary tumours, the metastatic load at the time of operation, the surgical margin, and the different techniques of reconstruction. The survival rate was 0.54 at one year and 0.27 at three years. Absence of visceral metastases and of a pathological fracture, a time interval of more than three years between the diagnosis of cancer and that of the first skeletal metastasis, thyroid carcinoma, prostate carcinoma, renal-cell carcinoma, breast cancer, and plasmacytoma were positive variables with regard to survival. The metastatic load of the skeleton and the surgical margin were not of significant influence. In tumours of the limbs and pelvis, the local failure rate was 0% after biological reconstruction (10), 3.6% after cemented or uncemented osteosynthesis (28) and 1.8% after prosthetic replacement (53). The local failure rate after stabilisation of the spine (18) was 16.6%. There was local recurrence in seven patients (6.4%), and in four of these the primary tumour was a renal-cell carcinoma. The local recurrence rate was 0% after extralesional (24) and 8.2% after intralesional resection (85). Improvements in the oncological management of patients with primary and metastatic disease have resulted in an increased survival rate. In order to avoid additional surgery, it is essential to consider the expected time of survival of the reconstruction and, in bony metastases with a potentially poor response to radiotherapy, the surgical margin

Aims

The aim of this study was to assess the ability of morphological spinal parameters to predict the outcome of bracing in patients with adolescent idiopathic scoliosis (AIS) and to establish a novel supine correction index (SCI) for guiding bracing treatment.

Statement of purpose. We review the current state of development of proton therapy and the implications for beam therapy in the management of primary bone tumours. Introduction. The principle of radiotherapy is to deliver a high dose, accurately, to the tumour. Conventional photon and proton therapy irradiates adjacent tissue significantly. This is reduced with intensity modulated proton therapy (IMPT). This has been demonstrably effective in treating tumours refractory to chemotherapy and conventional radiotherapy such as chrondrosarcomas and chordomas. Case Report. We present a patient with an isolated chondrosarcoma involving the anterior and posterior element of the L3 vertebral body with a significant soft tissue component displacing the IVC. The patient underwent a 2 stage en-bloc excision of the tumour: Stabilization was achieved by posterior L2-4 instrumented fusion with PEEK rods, an anterior PEEK cage and bone graft. Post-operatively the patient underwent 12 weeks of bed rest followed by rehabilitation. Due to pedicle involvement (giving a high risk of contamination) and the narrow clear margin found on histology the patient has been accepted for post-operative IMPT. Discussion. The high risk of contamination and the narrow margins presented an ideal case for post-operative IMPT. However, conventionally the stabilization would have been metallic, distorting the treatment mapping and the delivery of the IMPT, reducing any possible benefit. Thus, we used PEEK as it is proven to maintain its properties when subjected to a wide range of conditions while also being tolerant of, and not interfering with, most forms of radiation including proton therapy, maximising the chance of a positive outcome. One concern is that PEEK is less biomechanically stable then metal, hence the prolonged period of bed rest. Conclusion. This report discusses the current evidence for proton therapy while describing a successful technique for stabilization to facilitate delivery of proton treatment post-operatively

Statement of purpose. We review the current state of development of proton therapy and the implications for beam therapy in the management of primary bone tumours. Introduction. The principle of radiotherapy is to deliver a high dose, accurately, to the tumour. Conventional photon and proton therapy irradiates adjacent tissue significantly. This is reduced with intensity modulation proton therapy (IMPT). This has been demonstrably effective in treating tumours refractory to chemotherapy and conventional radiotherapy such as chrondrosarcomas and chordomas. Case Report. We present a patient with an isolated chondrosarcoma involving the anterior and posterior element of the L3 vertebral body with a significant soft tissue component displacing the IVC. The patient underwent a 2 stage en-bloc excision of the tumour: Stabilisation was achieved by posterior L2-4 instrumented fusion with Peek rods and screws, an anterior Peek cage and bone graft. Post-operatively the patient underwent 12 weeks of bed rest followed by rehabilitation. Due to pedicle involvement (giving a high risk of contamination) and the narrow clear margin found on histology the patient has been accepted for post-operative IMPT. Discussion. The high risk of contamination and the narrow margins presented an ideal case for post-operative IMPT. However, conventionally the stabilisation would have been metallic, distorting the treatment mapping and the delivery of the IMPT, reducing any possible benefit. Thus, we used Peek as it is proven to maintain its properties when subjected to a wide range of conditions while also being tolerant of, and not interfering with, most forms of radiation including proton therapy, maximising the chance of a positive outcome. One concern with Peek is that it is less biomechanically stable then metal, hence the prolonged period of bed rest. Conclusion. This report discusses the current evidence for proton therapy while describing a successful technique for stabilisation to facilitate delivery of proton treatment post-operatively. Ethics approval. None Audit/service standard in trust Ethics committee COREC number:. Interest Statement. None Local grant/National grant Commercial/industry support

Aims

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.

Sacro-coccygeal chordomas pose a difficult diagnostic and therapeutic problem due to late presentation, large size, soft-tisue extension, difficulties in obtaining adequate resection margins, higher local recurrence rate and uncertain effectiveness of adjuvant treatment. We present a series of 21 patients of sacral chordomas obtained from Scottish Bone Tumour Registry to analyse predictors of local control and survival. The clinical and morphologic features, type of treatment and follow-up of 21 consecutive patients with sacral chordoma were retrospectively reviewed and analysed. The data were obtained from Scottish Bone Tumour Registry. The average age at time of the biopsy was 59 years (range, 12 to 82 years): twelve patients were male and nine were female. Pain was the presenting symptom in all patients. Two had intralesional (both recurred), 9 marginal (4 recurred) and 3 wide resections (1 recurred). Fifteen of the twenty-one patients were treated with adjuvant radiation therapy. In seven patients, the chordoma was inoperable and all but one were treated with adjuvant radiotherapy. Local recurrence and metastases occurred in 7 (50%) and 5 (23.8%) patients. The 5-year and 10-year survival were 38% and 14.2%, respectively. Excision of the lesion combined with adjuvant radiation therapy provided satisfactory results. Local recurrence presents a major problem in the management of sacral chordomas (50%). Intralesional resection should be avoided as it is associated with 100% local recurrence in our series

Background. Fissures in the anulus fibrosus are common in disc degeneration, and are associated with discogenic pain. We hypothesise that anulus fissures are conducive to the ingrowth of blood vessels and nerves. Purpose. To investigate the mechanical and chemical micro-environment of anulus fissures. Methods. Six thoracolumbar spine specimens, comprising three vertebrae and two discs, were obtained from cadavers aged 68-83 yr. Discs were injected with blue dye to reveal the location of complete anulus fissures. Each specimen was then subjected to 1000 N compression, while intradiscal compressive stress was investigated by pulling a miniature pressure transducer through the disc, in planes likely to cross the anulus fissures. Some additional disc fragments were removed at surgery from patients with discogenic back pain, and examined histologically to gauge the concentration of collagen and proteoglycans within radial fissures, using a qualitative method. Results. Stress profiles were obtained perpendicular to major anulus fissures in seven discs. A marked local reduction in vertically-acting compressive stress usually coincided with fissure location (confirmed at dissection), and stress reductions were inversely proportional to average pressure in the nucleus (r. 2. =0.56, p<0.05). Surgical disc samples showed local depletion of proteoglycans around the margins of radial and circumferential fissures, leaving a collagen-rich scaffold of the type known to support nerve and blood vessel growth. Conclusion. Compressive stresses within anulus fissures are reduced most when the disc nucleus is decompressed, because this facilitates internal displacements of disrupted tissue. Anulus fissures provide a micro-environment that is mechanically and chemically conducive to the ingrowth of blood vessels and nerves

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

Spinal fusion, ending caudally at L5 rather than at the sacrum, is recommended for selected patients with scoliosis due to Duchenne muscular dystrophy. We present a retrospective review of 48 patients operated on for this condition. Patients having spinal curvature with a Cobb angle of less than 40° and with less than 10° between a line tangential to the superior margins of both iliac crests and a line perpendicular to the spinous processes of L4 and L5, were fused to L5 (38 patients); patients not meeting these criteria were fused to the sacrum (10 patients). Spinal and sitting obliquity increased in patients fused to L5, rather than to the sacrum, but the severity of the worsening obliquity was significantly greater in patients in whom the apex of the curve was below L1. Two of the ten latter patients required revision procedures for worsening obliquity when their pulmonary function deteriorated to less than 25% of predicted values. We recommend fusion to the sacrum for scoliosis in Duchenne muscular dystrophy, especially for patients with an apex to their curve below L1

Study design. Literature review of the best available evidence on the accuracy of computer assisted pedicle screw insertion. Background. Pedicle screw misplacement rates with the conventional insertion technique and adequate postoperative CT examination have ranged from 5 to 29 % in the cervical spine, from 3 to 58 % in the thoracic spine, and from 6 to 41% in the lumbosacral region. Despite these relatively high perforation rates, the incidence of reported screw-related complications has remained low. Interestingly, the highest rates of neurovascular injuries have been reported from the lumbosacral spine in up to 17% of the patients. Gertzbein and Robbins introduced a 4-mm “safe zone” in the thoracolumbar spine for medial encroachment, consisting of 2-mm of epidural and 2-mm of subarachnoid space. Later, several authors have found the safety margins to be significantly smaller, suggesting that the “safe zone” thresholds of Gertzbein and Robbins do not apply to the thoracic spine, and seem to be too high even for the lumbar spine. The midthoracic and midcervical spine, as well as the thoracolumbar junction set the highest demands for accuracy in pedicle screw insertion, with no room for either translational or rotational error at e.g. T5 level. Computer assisted pedicle screw insertion (navigation) was introduced in the early 90's to increase the accuracy and safety of pedicle screw insertion. Material. PubMed literature search revealed two randomized controlled trials (RCT) comparing the in vivo accuracy of conventional and computer assisted pedicle screw insertion techniques. Three meta-analyses have assessed the published reports on the accuracy of pedicle screw insertion with or without computer assistance, one additional meta-analysis concentrated on the functional outcome of computer assisted pedicle screw insertion. Results. The RCTs by Laine et al and Rajasekaran et al achieved significantly higher screw placement accuracy with computer assistance than with the conventional techniquebased on anatomical landmarks. In a degenerative patient population, Laine et al reported a misplacement rate of 4.6% with computer assistance compared to 13.4% with the conventional technique. In addition to this quantitative difference, a qualitative difference in the misplaced screws was noticed: in the conventional group, 28 out of 37 misplaced screws were either inferior or medial, whereas in the computer assisted group, 1 out of 10 misplaced screws was situated in these ”danger zones”. In deformity surgery, Rajasekaran et al reported a 2% pedicle screw misplacement rate with a computer assisted technique compared to 23% with the conventional technique. Interestingly, in their study, the average screw insertion time in the computer assisted group was significantly shorter than with the conventional technique. The three meta-analyses, assessing up to 37 337 pedicle screws, reported significantly higher accuracy in the placement of pedicle screws with computerassistance compared with the conventional methods. The superiority of the computer assisted technique was even more obvious with abnormal surgical anatomy. CT-based and 3D-fluoroscopy-based navigation methods provided better accuracy compared to 2Dfluoroscopy-based navigation. No statistically significant benefit with computer assistance in the incidence of neuro-vascular complications, or in functional outcome was demonstrated. Conclusion. High pedicle screw misplacement rates have been reported with the conventional technique based on anatomical landmarks and intraoperative fluoroscopy. The concept of ”safe zone” is hypothetical, and underestimates the true risks of misplaced pedicle screws. Computer assistance significantly improves the accuracy and safety of pedicle screw insertion. It will, however, be difficult to correlate this increased accuracy to improved patient outcomes

Aims

The aim of this study was to investigate the impact of maturity status at the time of surgery on final spinal height in patients with an adolescent idiopathic scoliosis (AIS) using the spine-pelvic index (SPI). The SPI is a self-control ratio that is independent of age and maturity status.