Aims. The aim of this study was to evaluate whether, after correction of an adolescent idiopathic scoliosis (AIS), leaving out the subfascial drain gives results that are no worse than using a drain in terms of total blood loss, drop in haemoglobin level, and opioid consumption. Methods. Adolescents (aged between 10 and 21 years) with an idiopathic scoliosis (major curve ≥ 45°) were eligible for inclusion in this randomized controlled noninferiority trial (n = 125). A total of 90 adolescents who had undergone segmental pedicle screw instrumentation were randomized into no-drain or drain groups at the time of wound closure using the sealed envelope technique (1:1). The primary outcome was a drop in the haemoglobin level during first three postoperative days. Secondary outcomes were 48-hour postoperative oxycodone consumption and surgical complications. Results. All 90 patients were included in the primary outcome analysis (no drain = 43; drain = 47). The mean total postoperative blood loss (intraoperative and drain output) was significantly higher in the group with a subfascial drain than in the no-drain group (1,008 ml (SD 520) vs 631 ml (SD 518); p < 0.001). The drop in haemoglobin level did not differ between the study groups over the postoperative timepoints (p = 0.290). The 48-hour opioid consumption was significantly higher in the no-drain group (2.0 mg/kg (SD 0.9) vs 1.4 (SD 0.6); p = 0.005). Two patients in the no-drain and one patient in the drain group developed a surgical site infection. Conclusion. Leaving the subfascial drain out after pedicle screw instrumentation for AIS is not associated with higher postoperative haemoglobin levels. Patients treated without a subfascial drain needed 30% more opioids during the first 48 hours than those who had a drain. Cite this article: Bone Joint J 2022;104-B(9):1067–1072

Purpose of the study. To investigate the efficacy of pedicle screw instrumentation in correcting spinal deformity in patients with quadriplegic cerebral palsy. Also to assess quality of life and functional improvement after deformity correction as perceived by the parents of our patients. Summary of Background Data. All pedicle screw constructs have been commonly used to correct adolescent idiopathic scoliosis. There is limited information on their effectiveness in treating patients with cerebral palsy and neuromuscular scoliosis. Methods. We reviewed the medical records and serial radiographs of 45 consecutive patients with quadriplegia who underwent spinal arthrodesis using pedicle screw/rod instrumentation and a standardised surgical technique (prospectively collected single surgeon's series). All patients were wheelchair bound with collapsing thoracolumbar scoliosis and pelvic obliquity. Twenty-eight patients had associated sagittal deformities. A telephone survey was performed by an independent investigator to assess parents' perception on surgical outcome. Results. Thirty-eight patients underwent posterior-only and 7 staged anteroposterior spinal arthrodesis. Mean age at surgery was 13.4 years (range 9-18.3) and mean postoperative follow-up 3.5 years (range 2.8-5). Pedicle screw instrumentation extended from T2/T3 to L5 with bilateral pelvic fixation using iliac bolts. Scoliosis was corrected from mean 82.5° to 21.4° (74.1%). Pelvic obliquity was corrected from mean 24° to 4° (83.3%). In posterior-only procedures, average blood loss was 0.8 blood volumes, ICU stay 3.5 days, and hospital stay 17.6 days. In anteroposterior procedures, average blood loss was 0.9 blood volumes, ICU stay 8.9 days, and hospital stay 27.4 days. Major complications included one deep infection and one re-operation to remove prominent implants but no deaths, no neurological deficit and no detected pseudarthrosis. Parents' survey demonstrated 100% satisfaction rate. Conclusion. Pedicle screw instrumentation can achieve excellent correction of spinopelvic deformity in quadriplegic cerebral palsy with low complication and re-operation rates and high parent satisfaction. Our study has demonstrated that spinal correction using segmental pedicle screw/rod constructs can be performed safely and with lesser major complications and reoperations compared to the traditionally used Unit rod or hybrid instrumentation. The greater degree of deformity correction and lesser rate of complications and reoperations due to non-union, prominent instrumentation or failed pelvic fixation using a pedicle screw compared to the Unit rod technique should be balanced against the increased implant cost

We reviewed 212 consecutive patients with adolescent idiopathic scoliosis who underwent posterior spinal arthrodesis using all pedicle screw instrumentation in terms of clinical, radiological and Scoliosis Research Society (SRS)-22 outcomes. In Group 1 (51 patients), the correction was performed over two rods using bilateral segmental pedicle screws. In Group 2 (161 patients), the correction was performed over one rod using unilateral segmental pedicle screws with the second. rod providing stability of the construct through two-level screw fixation at proximal and distal ends. The mean age at surgery was 14.8 years in both groups. Comparison between groups showed no significant differences with regard to age and Risser grade at surgery, pre- and post-operative scoliosis angle, coronal Cobb correction, length of hospital stay and SRS scores. Correction of upper thoracic curves was significantly better in Group 1 (p = 0.02). Increased surgical time and intra-operative blood loss was recorded in Group 1 (p < 0.001 and p = 0.04, respectively). The implant cost was reduced by mean 35% in Group 2 due to the lesser number of pedicle screws. Unilateral and bilateral pedicle screw techniques have both achieved excellent deformity correction in adolescent patients with idiopathic scoliosis, which was maintained at two-year follow-up. This has been associated with high patient satisfaction and low complication rates

Anterior instrumentation is an established method of correcting King I adolescent idiopathic scoliosis. Posterior segmental pedicle screw instrumentation, with its more powerful corrective force over hooks, could offer significant advantages. The purpose of our study is to compare the results of anterior instrumentation versus segmental pedicle screw instrumentation in adolescent idiopathic thoracolumbar scoliosis. A retrospective analysis was conducted on 36 consecutive female patients with adolescent idiopathic thoracolumbar scoliosis who had surgery from December 1997. All had a minimum of two year follow-up. Eleven patients had posterior surgery performed on them. Mean age at surgery was similar between both groups. Length of surgery was significantly shorter in the posterior group (189 minutes versus 272 minutes). Length of hospital stay was shorter in the posterior group (6.2 days versus eight days). Estimated blood loss, duration of analgesia, and ICU stay did not differ significantly between the two groups. No complications were encountered in both groups at latest follow-up. The magnitudes and flexibility of the thoracolumbar curves did not differ significantly between the two groups. The number of levels in the major curve was also similar between the groups. Fusion levels were shorter in the anterior group (mean 4.1 versus 5.0). The percentage correction of scoliosis was similar between the two groups at all stages of follow-up, being 74% at one week post-surgery, 70% at six months post-surgery, 68% at one year post-surgery and latest follow-up in the anterior group; and 71% at one week post-surgery, 67% at six months post-surgery, 68% at one year post-surgery, and 67% at latest follow-up in the posterior group. Thoracolumbar sagittal alignment at T11 to L2 was maintained for both groups throughout the follow-up period. The incidence of proximal junctional kyphosis was higher in the posterior group (p < 0.01). In conclusion, surgical correction of both the frontal and sagittal plane deformity are comparable to anterior instrumentation. Shorter length of surgery and hospital stay are the potential benefits of posterior surgery. Posterior segmental pedicle screw instrumentation offers significant advantage, and is a viable alternative to standard anterior instrumentation in idiopathic thoracolumbar scoliosis

Introduction: Rotation is becoming an increasingly important consideration in the management of scoliosis yet it is difficult to measure reliably. The Perdriolle technique is a widely used and validated technique for estimating the rotation of the apical vertebra. The landmarks required to measure vertebral rotation using this technique are frequently obscured following instrumentation and the application of bone graft. We propose that the Perdriolle technique cannot be applied reliably in the presence of pedicle screw constructs. Method: This was a manual radiographic measurement analysis comparing intraobserver and interobserver reliability of the Perdriolle “Torsiometre” and the Cobb angle measurement in scoliosis prior to and after pedicle screw instrumentation. Results: Mean difference and 95% limits of agreement between pre-operative intra-observer readings was 2.5° (−15° and 20°). This suggests on average there was little systematic disagreement between the two readings (2.5° on average). There were large discrepancies between individual pairs of readings. 29.6% of post-operative films (17%–39%) were judged to have sufficient landmarks visible to enable measurement of vertebral rotation compared to 10% of pre-operative films. Marked increase in systematic bias between consultants with post-operative radiographs to pre-operative films was observed. Conclusion: We question the validity in measuring the rotation of the curve using the Perdriolle technique on post-operative films following pedicle screw instrumentation. The predominant factors for the obscuration of landmarks include the presence of bone graft, pedicle screws and rods

The aim of this study was to compare the treatment ouctomes of severe idiopathic scoliosis (IS) (>90 degrees) using the staged surgery with initial limited internal distraction and typical IS treated using segmental pedicle screw instrumentation. We hypothesized that staged surgical treatment of severe scoliosis would improve more HRQoL and pulmonary function (PF) as compared with posterior spinal fusion (PSF) for typical IS curves. It was a retrospective review of a consecutive series of 60 IS, severe group (SG) vs. moderate group (MG) with min. 2 years of follow up (FU). The mean preoperative major curve (MC) was 120° and thoracic kyphosis (TK) was 80° for the SG and 54° and 17° for the MG, respectively (p<0.001). The MC was corrected to 58° and TK to 32° for the SG; the MC to 26° and TK to 14°, for the MG, respectively (p<0.001). The mean preoperative AVT was 8.9 cm and improved to 2.8 cm at the final FU for the SG and from 6.5 cm to 2.2 cm at the final FU for the MG (p<0.001). At baseline, the FVC% & FEV1% values were significant different between the two groups (41.5% vs. 83%, p <0.001) & (41.6% vs. 77%, p <0.001). Compared the baseline for SG vs. the values at 2-year FU the FVC % values were (41.5% vs. 66.5%, p <0.001), and the baseline for MG vs. the values at 2-year FU, the FEV1 values were (77% vs. 81%, NS). At last FU, no complications were reported. Gradual traction with complicity of multilevel Ponte's osteotomies and neuromonitoring followed by staged pedicle screws instrumentation in severe IS proved to be a safe and effective method improving spinal deformity (52% correction), PF (improved percentage of predicted forced vital capacity by 49%), and health-related quality and allows to achieve progressive curve correction with no neurologic complications associated to more aggressive one-stage surgeries

Objective. To evaluate the outcomes of the treatment of acute thoracolumbar burst fractures by transpedicular balloon kyphoplasty with Calcium phosphate cement and posterior instrumented fusion. Methods: Twenty-three consecutive patients (average age 48 years) who sustained thoracolumbar A3-type burst fracture with or without neurologic deficit were included in this prospective study. Twenty-one out 23 patients had single fractures and the left 2 had each one additional A1 compression contiguous fracture. On admission 5(26%) out 23 patients had neurologic lesion (5 incomplete, one complete). Bilateral transpedicular balloon kyphoplasty was performed with quick hardening calcium phosphate cement to reduce segmental kyphosis and restore vertebral body height and supplementary pedicle screw instrumentation (long including 4 vertebrae for T9-L1 fractures and short (3 vertebrae) for L2 to L4 fractures. Gardner kyphosis angle, anterior and posterior vertebral body height ratio and spinal canal encroachment were calculated pre–to postoperatively. Results: All 23 patients were operated within two days after admission and were followed for at least 24 months after index surgery. Operating time and blood loss averaged 70 minutes and 250 cc respectively. The 5 patients with incomplete neurologic lesions improved by at least one ASIA grade, while no neurological deterioration was observed in any case. Overall sagittal alignment was improved from an average preoperative 16o to one degree kyphosis at final follow up observation. The anterior vertebral body height ratio improved from 0.6 preoperatively to 0.9 (P< 0.001) postoperatively, while posterior vertebral body height was improved from 0.95 to 1 (P< 0.01). Spinal canal encroachment was reduced from an average 32% preoperatively to 20% postoperatively. No differences in preoperative values and postoperative changes in radiographic parameters between short and long group were shown. Cement leakage was observed in 4 cases: three anterior to vertebral body and one into the disc without sequalae. In the last CT evaluation, continuity was shown between calcium phosphate and cancellous vertebral body bone. Posterolateral radiological fusion was achieved within 6–8 months after index operation. There was no instrumentation failure or measurable loss of sagittal curve and vertebral height correction in any group of patients. Conclusions: Balloon kyphoplasty with calcium phosphate cement secured with posterior long and short fixation in the thoracolumbar and lumbar spine respectively provided excellent immediate reduction of posttraumatic segmental kyphosis and significant spinal canal clearance and restored vertebral body height in the fracture level in an equal amount both in short and long instrumentation

Lowest instrumented vertebra (LIV) selection is critical to preventing complications following posterior spinal arthrodesis (PSA) for thoracolumbar/lumbar adolescent idiopathic scoliosis (TL/L AIS), but evidence guiding LIV selection is limited. This study aimed to investigate the efficacy of PSA using novel unilateral convex segmental pedicle screw instrumentation (UCS) in correcting TL/L AIS, to identify radiographic parameters correlating with distal extension of PSA, and to develop a predictive equation for distal fusion extension using these parameters. We reviewed data (demographic, clinical, radiographic, and SRS-22 questionnaires) preoperatively to 2-years' follow-up for TL/L AIS patients treated by PSA using UCS between 2006 to 2011. 53 patients were included and divided into 2 groups: Group-1 (n=36) patients had PSA between Cobb-to-Cobb levels; Group-2 (n=17) patients required distal fusion extension. A mean curve correction of 80% was achieved. Mean postoperative LIV angle, TL/L apical vertebra translation (AVT), and trunk shift were lower than previous studies. Six preoperative radiographic parameters significantly differed between groups and correlated with distal fusion extension: thoracic curve size, thoracolumbar curve size, LIVA, AVT, lumbar flexibility index, and Cobb angle on lumbar convex bending. Regression analysis optimised an equation (incorporating the first five parameters) which is 81% accurate in predicting Cobb-to-Cobb fusion or distal extension. SRS-22 scores were similar between groups. We conclude that TL/L AIS is effectively treated by PSA using UCS, six radiographic parameters correlate with distal fusion extension, and a predictive equation incorporating these parameters reliably informs LIV selection and the need for fusion extension beyond the caudal Cobb level

A retrospective descriptive preliminary study on early experience using all pedicle screw correction

Pedicle screw fixation enables enhanced correction of spinal deformities. However, the technique is still in early development in our clinic. Tends of the scoliosis patient to come in late ages make maximum correction failed.

A total 16 patients are subjected to pedicle screw fixation for spinal deformities were analyzed descriptively as an early follow-up in the last two-year. 14 patients are girl and 2 are boys. The age range between 12 to 18 year. 8 are Kings type II and 8 are Kings type III, 212 screws were inserted between Th3 – L2 (14-18 screws per-patient), all concave pedicles were inserted with screws but in convex side every two or three pedicles were inserted. The position of screws was analyzed using the post-operative plain X ray film.

Before surgery the mean deformity measurement are 52.56° (range, 42-72°, correction achieved was 18° (range 10-34%, it was correlated to 68% achievement (range, 53-80%). All patients are happy with their image improvement.

In total 212 screws inserted, 28 screws are malpositions (13.2%), but no clinical complication recorded.

In this early experience using all pedicle screw scoliosis surgery, all patients are happy with the results although the correction only 53-80(. More patients are needed to improve this achievement.

Introduction: Historically segmental sublaminar wiring (SLW) fixation has been used for the correction of spinal deformity in neuromuscular scoliosis, however pedicle screw (PS) fixation is gaining popularity. We compared the results of both techniques in patients with Duchenne Muscular Dystrophy (DMD).

Methods: Two groups of patients with DMD were matched according to the age at surgery, magnitude of deformity and vital capacity. Indications for surgery included loss of sitting balance, rapid decline of vital capacity and curve progression. In Group 1 (22 patients) SLW fixation was used from T2 to S1 with the Galveston technique. In Group 2 (18 patients) PS fixation was used from T2 to L5. Minimum follow-up was 2 years (range 2–13 years). Radiographs, SRS-22 and lung function tests were performed at standardised intervals.

Results: Mean Cobb angle in Group 1 improved from 47° (range 26°–75°) to 23.5° (range10°–36°) and mean pelvic obliquity improved from 15° (range8°–25°) to 2.4° (range0°–8°). Mean Cobb angle in Group 2 improved from 46° (range28°–82°) to 8.5° (range 0°–18°) and mean pelvic obliquity improved from 15° (range7°–30°) to 1.1° (range 0°–6°) [p< 0.05]. Mean operating time and blood loss were less in Group 2 [p< 0.05]. In Group 1, the infection rate and instrumentation failure was higher, and SRS-22 outcomes showed no significant difference between the groups. Interestingly the mean Body Mass Index (BMI) in Group 2 was much higher than group 1.

Conclusions: PS fixation resulted in superior correction and controlled pelvic obliquity to a large extent without the need for pelvic fixation. Lower rates of infection and failure of instrumentation were noted with PS fixation, despite high BMI of patients presumably due to steroid therapy. We recommend the use of PS instrumentation for the correction of spinal deformity in DMD.

Purpose

Bone morphogenic protein (BMP-2) is used in spinal arthrodesis to induce bone growth. Studies have demonstrated that it achieves similar fusion rates compared to iliac crest bone graft when used in instrumented fusions. Our study aims at evaluating the requirement for instrumentation in one and two-level spinal arthrodeses when BMP-2 is used in conjunction with local bone to achieve fusion.

Aims. Closed suction subfascial drainage is widely used after instrumented posterior spinal fusion in patients with a spinal deformity. The aim of this study was to determine the effect of this wound drainage on the outcomes in patients with adolescent idiopathic scoliosis (AIS). This was a further analysis of a randomized, multicentre clinical trial reporting on patients after posterior spinal fusion using segmental pedicle screw instrumentation. In this study the incidence of deep surgical site infection (SSI) and chronic postoperative pain at two years’ follow-up are reported. Methods. We conducted a randomized, multicentre clinical trial on adolescents undergoing posterior spinal fusion for AIS using segmental pedicle screw instrumentation. A total of 90 consecutive patients were randomized into a ‘drain’ or ‘no drain’ group at the time of wound closure, using the sealed envelope technique (1:1). The primary outcomes in the initial study were the change in the level of haemoglobin in the blood postoperatively and total blood loss. A secondary outcome was the opioid consumption immediately after surgery. The aim of this further study was to report the rate of deep SSI and persistent postoperative pain, at two years' follow-up. Results. As previously reported, the mean 48-hour opioid consumption was significantly higher in the no drain group (2.0 mg/kg (SD 0.8) vs 1.4 mg/kg (SD 0.7); p = 0.005). There were no delayed deep SSIs. At two years’ follow-up, the mean Scoliosis Research Society 24-item questionnaire (SRS-24) total score did not differ between the groups (4.11 (SD 0.47) vs 4.16 (SD 0.33); p = 0.910). The mean SRS-24 pain score was 4.28 (SD 0.48) in the no drain group compared with 4.33 (SD 0.66) in the drain group (p = 0.245). Seven patients (19%) in the no drain group and six in the drain group (14%) reported moderate to severe pain (numerical rating scale ≥ 4) at two years’ follow-up (p = 0.484). The general self-image domain score was significantly higher in the no drain group compared with the drain group (4.02 (SD 0.74) vs 4.59 (SD 0.54); p < 0.001). Conclusion. The main finding in this study was that more severe pain immediately after surgery did not result in a higher incidence of chronic pain in the no drain group compared with the drain group. Back pain and health-related quality of life at two years’ follow-up did not differ between the groups. The patient-reported self-image domain was significantly better in the no drain group compared with the drain group. Cite this article: Bone Joint J 2024;106-B(10):1176–1181

Objectives: To determine if high quality, thin slice (1–3)mm CT scan images would allow proper evaluation of interbody fusion through titanium cages in view of the fact that there are no universally accepted radiological criteria. ¹

Design: Patients undergoing interbody lumbar fusion were prospectively evaluated with a CT scan and plain radiographs six months following surgery. These were blindly and independently evaluated by a consultant radiologist and a research fellow. They were assessed for bridging bony trabeculation both through and surrounding the cages as well as for changes at the cage endplate interface.

Subjects: Fifty-three patients (156 cages) undergoing posterior lumbar interbody fusion using titanium inter-body cages were evaluated. Posterior elements were used to pack the cages and no graft was packed outside the cages.

Outcome Measures: Kappa co-efficient and chi-squared analysis.

Results: On the CT scan both observers noted bridging trabeculation in 95%of the cages-Kappa 0.85, while on radiographs they were present in only 4%-Kappa 0.74. Both observers also identified bridging trabeculation surrounding the cages on the CT scans in 90%-Kappa 0.82, while on the radiographs this was 8%-Kappa 0.86. Radiographs also did not identify all the loose cages.

Conclusions: High quality CT scan images can demonstrate bridging bony trabeculation following the use of titanium interbody cages. It also demonstrated consistent bone growth outside the cages inspite of not using any bone graft.

Aim:

To determine radiographic variables that predict the need for distal extension of the fusion beyond Cobb-to-Cobb levels in treating thoracolumbar/lumbar (TL/L) scoliosis (Lenke 5) in adolescent patients.

We compared the clinical, radiological and quality-of-life outcomes between hybrid and total pedicle screw instrumentation in patients undergoing surgery for neuromuscular scoliosis. A matched comparison using prospectively collected data was undertaken. A total of 66 patients underwent posterior or anteroposterior correction and fusion with hybrid (n = 33, mean age at surgery 15.8 years (9.10 to 19.6)) or total pedicle screw instrumentation (n = 33, mean age 14.7 years (7.0 to 20.7)) with a minimum follow-up of two years. The major curve pre-operatively was a mean of 87° (. sd. 29, 25° to 141°) and 81° (. sd. 18, 47° to 116°) in the hybrid and total pedicle screw groups, respectively (p = 0.29) and at a minimum of two years it was 33° (. sd. 20; 2° to 87°) and 20° (. sd. 12; 1° to 55°), respectively (p = 0.0016). The mean correction of the major curve was 59% (41% to 88%) in the hybrid and 75% (43% to 99%) in the total pedicle screw groups at two-year follow-up (p = 0.0011). The mean operating time was 7.45 hours (. sd. 2.18) and 6.04 hours (. sd. 1.71) in the hybrid and total pedicle screw groups, respectively (p = 0.001), and the mean intra-operative blood loss was 3760 ml (. sd.  2790) and 1785 ml (. sd. 1110), respectively (p = 0.001). Total pedicle screw instrumentation provided shorter operating times, less blood loss and better correction of the major curve compared with hybrid constructs in patients undergoing surgery for neuromuscular scoliosis

Aims

In a multicentre, randomised study of adolescents undergoing posterior spinal fusion for idiopathic scoliosis, we investigated the effect of adding gelatine matrix with human thrombin to the standard surgical methods of controlling blood loss.

Clinical, radiological, and Scoliosis Research Society-22 questionnaire data were reviewed pre-operatively and two years post-operatively for patients with thoracolumbar/lumbar adolescent idiopathic scoliosis treated by posterior spinal fusion using a unilateral convex segmental pedicle screw technique. A total of 72 patients were included (67 female, 5 male; mean age at surgery 16.7 years (13 to 23)) and divided into groups: group 1 included 53 patients who underwent fusion between the vertebrae at the limit of the curve (proximal and distal end vertebrae); group 2 included 19 patients who underwent extension of the fusion distally beyond the caudal end vertebra.

A mean scoliosis correction of 80% (45% to 100%) was achieved. The mean post-operative lowest instrumented vertebra angle, apical vertebra translation and trunk shift were less than in previous studies. A total of five pre-operative radiological parameters differed significantly between the groups and correlated with the extension of the fusion distally: the size of the thoracolumbar/lumbar curve, the lowest instrumented vertebra angle, apical vertebra translation, the Cobb angle on lumbar convex bending and the size of the compensatory thoracic curve. Regression analysis allowed an equation incorporating these parameters to be developed which had a positive predictive value of 81% in determining whether the lowest instrumented vertebra should be at the caudal end vertebra or one or two levels more distal. There were no differences in the Scoliosis Research Society-22 outcome scores between the two groups (p = 0.17).

In conclusion, thoracolumbar/lumbar curves in patients with adolescent idiopathic scoliosis may be effectively treated by posterior spinal fusion using a unilateral segmental pedicle screw technique. Five radiological parameters correlate with the need for distal extension of the fusion, and an equation incorporating these parameters reliably informs selection of the lowest instrumented vertebra.

Cite this article: Bone Joint J 2014;96-B:1082–9.

Aims. It is uncertain whether instrumented spinal fixation in nonambulatory children with neuromuscular scoliosis should finish at L5 or be extended to the pelvis. Pelvic fixation has been shown to be associated with up to 30% complication rates, but is regarded by some as the standard for correction of deformity in these conditions. The incidence of failure when comparing the most caudal level of instrumentation, either L5 or the pelvis, using all-pedicle screw instrumentation has not previously been reported. In this retrospective study, we compared nonambulatory patients undergoing surgery at two centres: one that routinely instrumented to L5 and the other to the pelvis. Methods. In all, 91 nonambulatory patients with neuromuscular scoliosis were included. All underwent surgery using bilateral, segmental, pedicle screw instrumentation. A total of 40 patients underwent fusion to L5 and 51 had their fixation extended to the pelvis. The two groups were assessed for differences in terms of clinical and radiological findings, as well as complications. Results. The main curve (MC) was a mean of 90° (40° to 141°) preoperatively and 46° (15° to 82°) at two-year follow-up in the L5 group, and 82° (33° to 116°) and 19° (1° to 60°) in the pelvic group (p < 0.001 at follow-up). Correction of MC and pelvic obliquity (POB) were statistically greater in the pelvic group (p < 0.001). There was no statistically significant difference in the operating time, blood loss, or complications. Loss of MC correction (> 10°) was more common in patients fixated to the pelvis (23% vs 3%; p = 0.032), while loss of pelvic obliquity correction was more frequent in the L5 group (25% vs 0%; p = 0.007). Risk factors for loss of correction (either POB or MC) included preoperative coronal imbalance (> 50 mm, odds ratio (OR) 11.5, 95%confidence interval (CI) 2.0 to 65; p = 0.006) and postoperative sagittal imbalance (> 25 mm, OR 11.0, 95% CI1.9 to 65; p = 0.008). Conclusion. We found that patients undergoing pelvic fixation had a greater correction of MC and POB. The rate of complications was not different. Preoperative coronal and postoperative sagittal imbalance were associated with increased risks of loss of correction, regardless of extent of fixation. Therefore, we recommend pelvic fixation in all nonambulatory children with neuromuscular scoliosis where coronal or sagittal imbalance are present preoperatively. Cite this article: Bone Joint J 2020;102-B(2):261–267

We considered three different device systems for the treatment of lumbar and lumbosacral instability. From a prospective database in use in our Institution, we obtained a 45-patient cohort of individuals who received a one-level lumbar or lumbosacral fusion procedure between 1995 and 1998. All patients had presented with disabling back and/or radicular pain and severe degenerative changes at one disc level or low-grade spondylolisthesis. First group: 15 patients, six male and nine female, with an average age of 41 years, were treated by an interbody fusion using cylindrical threaded cages; the levels fused were L5-S1 in 10 patients and at L4-L5 in five. Second group: 15 patients, eight male and seven female, with an average age of 39 years were treated by nine cylindrical, threaded cages and seven square cages, combined with posterior pedicle screws; the levels fused were L5-S1 in 11 and L4-L5 in four. Third group: 15 patients, eight male and seven female, with an average age of 40 years, underwent posterolateral fusion with posterior pedicle screws instrumentation alone; the levels fused were L5-S1 in 10 and L4-L5 in the remaining five. At a mean follow-up of 8 years in the first group, eight patients (53%) required a second operation (five posterior instrumentation, two root decompression and one repair of dural tear). The clinical results were fair in six patients (40%) and poor in three (20%); five patients (33%) presented uncertain fusion signs. In the second group, two patients (13%) required a second operation (one root decompression and one dural repair). All patients (100%) presented definite fusion signs. The clinical results 6.5 years after primary surgery were fair in two (13%) patients and poor in two (13%). In the third group, two patients (13%) required a second operation (one dural repairand one implant removal). The clinical results were fair in two cases (13%) and no poor results were seen. At a mean follow-up of 6.5 years, 14 patients (93%) showed definite fusion signs. According to the present data, we can conclude that in terms of fusion success, clinical outcome and complication rates, the use of posterior interbody cages alone is not as safe and effective for the management of one level degenerative disc disease or low-grade spondylolisthesis as the posterior pedicle screw instrumentation combined with two posterior cages or the stand-alone pedicle screw instrumentation

There are few reports of the treatment of lumbar tuberculous spondylitis using the posterior approach. Between January 1999 and February 2004, 16 patients underwent posterior lumbar interbody fusion with autogenous iliac-bone grafting and pedicle screw instrumentation. Their mean age at surgery was 51 years (28 to 66). The mean follow-up period was 33 months (24 to 48). The clinical outcome was assessed using the Frankel neurological classification and the Kirkaldy-Willis criteria. On the Frankel classification, one patient improved by two grades (C to E), seven by one grade, and eight showed no change. The Kirkaldy-Willis functional outcome was classified as excellent in eight patients, good in five, fair in two and poor in one. Bony union was achieved within one year in 15 patients. The mean pre-operative lordotic angle was 27.8° (9° to 45°) which improved by the final follow-up to 35.8° (28° to 48°). Post-operative complications occurred in four patients, transient root injury in two, a superficial wound infection in one and a deep wound infection in one, in whom the implant was removed. Our results show that a posterior lumbar interbody fusion with autogenous iliac-bone grafting and pedicle screw instrumentation for tuberculous spondylitis through the posterior approach can give satisfactory results