Introduction/Aim. Intra-operative localisation of thoracic spine levels can be difficult due to anatomical constraints such as scapular shadow, patient's size and poor bone quality. This is particularly true in cases of thoracic discectomies in which the vertebral bodies appear normal. We describe a simple and reliable technique to identify the correct thoracic spine level. Methods. After induction of general anaesthesia, the patient is placed prone and the pedicle of interest is identified using fluoroscopy. A ‘K’ wire is then inserted percutaneously into this pedicle under image guidance (confirmed in the antero-posterior (AP) and lateral views). The ‘K’ wire is then cut flush and the patient is then positioned laterally and the intended procedure is performed. Results. We routinely use this technique in all our thoracic discectomies. Placing the ‘K’ wire into a fixed point like the pedicle, facilitates rapid intra-operative viewing of the level of interest and is removed easily at the conclusion of surgery. Conclusion. Per-operative placement of the ‘K’ wire avoids the patient undergoing two procedures as some of the other invasive techniques have described in the literature for correct level identification. Furthermore, this technique is simple and requires no more ability than placing an implant in the pedicle under fluoroscopy. It has the added advantage of reducing anaesthetic, surgery and fluoroscopy time

We present a large single surgeon case series evaluation of a new growth guidance technique for the treatment of progressive early onset scoliosis (EOS). A traditional Luque trolley construct uses wires to hold growth guidance rods together. We describe a new technique that uses domino end to side connectors in place of the wires with the aim of providing a stronger construct to better limit curve progression, while allowing longitudinal growth. We did a thorough retrospective review of patient records and radiological imaging. Sequential measurements of Cobb angle and length of rods were recorded, as well as any further surgical procedures and associated complications. This enabled us to quantify the ability of a technique to limit curve progression and simultaneously allow growth of the construct. In total, 28 patients with EOS (20 idiopathic, four syndromic, and four neuromuscular) have been treated with this technique, 25 of whom have a minimum follow-up of 2 years and 13 have a minimum follow-up of 5 years. The average correction of the preoperative Cobb angle was 48.9%. At the 2-year follow up, the average loss of this initial correction was 15 degrees, rising to only 20 degrees at a minimum of 5 years (including four patients with a follow-up of 8 years or more). The growth of the constructs was limited. The average growth at 2 years was 3.7 mm, rising to 19 mm at the 5-year follow-up. Patients who underwent surgery with this technique before the age of 8 years seemed to do better. This group had a revision rate of only 18% at an average time of 7 years after the index procedure, and the average growth was 22 mm. However, the group that had index surgery after the age of 8 years had a 64% revision rate at an average of 3.2 years after surgery and an average growth of only 11.6 mm. Overall, in the cases series, there were four hardware failures (14%) and one deep infection (3.5%), and only ten patients (36%) had one extra surgery after the index procedure. Only two of the 13 patients who are at a follow-up of 5 years or more have had revision. This modified Luque trolley technique has a good capacity for initial curve correction and for limiting further curve progression, with limited longitudinal growth before 2 years and improved growth thereafter. This technique might not be so useful after the age of 8 years because of poor growth and a higher early revision rate. We have also demonstrated a low cost technique with a low hardware failure rate that saves many future surgeries for the patient compared with other techniques used in the treatment of EOS

With the identification of literature shortfalls on the techniques employed in intraoperative navigated (ION) spinal surgery, we outline a number of measures which have been synthesised into a coherent operative technique. These include positioning, dissection, management of the reference frame, the grip, the angle of attack, the drill, the template, the pedicle screw, the wire, and navigated intrathecal analgesia. Optimizing techniques to improve accuracy allow an overall reduction of the repetition of the surgical steps with its associated productivity benefits including time, cost, radiation, and safety. Cite this article: Bone Joint J 2020;102-B(3):371–375

Fracture of a pedicle is a rare complication of spinal instrumentation using pedicular screws, but it can lead to instability and pain and may necessitate extension of the fusion. Osteosynthesis of the fractured pedicle by cerclage-wire fixation and augmentation of the screw fixation by vertebroplasty or temporary elongation of the fixation, allows stabilisation without sacrifice of the adjacent healthy segment. We describe three patients who developed a fracture of the pedicle in the most caudal instrumented vertebra early after lumbar spinal fusion. During revision surgery the pedicles were reduced and secured by a soft cerclage wire bilaterally. Fusion was obtained at the site of the primary instrumentation and healing of the pedicles was achieved. Cerclage wiring of the fractured pedicle seems to be safe and avoids permanent extension of the fusion without the sacrifice of an otherwise healthy segment

In spinal tuberculosis MRI can clearly demonstrate combinations of anterior and posterior lesions as well as pedicular involvement. We propose a classification system, using information provided by MRI, to help to plan the appropriate surgical treatment for patients with thoracic spinal tuberculosis. We describe a series of 47 patients, divided into four groups, based on the surgical protocol used in the management. Group A consisted of patients with anterior lesions which were stable with no kyphotic deformity, and were treated with anterior debridement and strut grafting. Group B comprised patients with global lesions, kyphosis and instability who were treated with posterior instrumentation using a closed-loop rectangle with sublaminar wires, and by anterior strut grafting. Group C were patients with anterior or global lesions as in the previous groups, but who were at a high risk for transthoracic surgery because of medical and possible anaesthetic complications. These patients had a global decompression of the cord posteriorly, the anterior portion of the cord being approached through a transpedicular route. Posterior instrumentation was with a closed-loop rectangle held by sublaminar wires. Group D comprised patients with isolated posterior lesions which required posterior decompression only. An understanding of the extent of vertebral destruction can be obtained from MRI studies. This information can be used to plan appropriate surgery

Injury to the spinal cord and kyphosis are the two most feared complications of tuberculosis of the spine. Since tuberculosis affects principally the vertebral bodies, anterior decompression is usually recommended. Concomitant posterior instrumentation is indicated to neutralise gross instability from panvertebral disease, to protect the anterior bone graft, to prevent graft-related complications after anterior decompression in long-segment disease and to correct a kyphosis. Two-stage surgery is usually performed in these cases. We present 38 consecutive patients with tuberculosis of the spine for whom anterior decompression, posterior instrumentation, with or without correction of the kyphus, and anterior and posterior fusion was performed in a single stage through an anterolateral extrapleural approach. Their mean age was 20.4 years (2.0 to 57.0). The indications for surgery were panvertebral disease, neurological deficit and severe kyphosis. The patients were operated on in the left lateral position using a ‘T’-shaped incision sited at the apex of kyphosis or lesion. Three ribs were removed in 34 patients and two in four and anterior decompression of the spinal cord was carried out. The posterior vertebral column was shortened to correct the kyphus, if necessary, and was stabilised by a Hartshill rectangle and sublaminar wires. Anterior and posterior bone grafting was performed. The mean number of vertebral bodies affected was 3.24 (2.0 to 9.0). The mean pre-operative kyphosis in patients operated on for correction of the kyphus was 49.08° (30° to 72°) and there was a mean correction of 25° (6° to 42°). All except one patient with a neural deficit recovered complete motor and sensory function. The mean intra-operative blood loss was 1175 ml (800 to 2600), and the mean duration of surgery 3.5 hours (2.7 to 5.0). Wound healing was uneventful in 33 of 38 patients. The mean follow-up was 33 months (11 to 74). None of the patients required intensive care. The extrapleural anterolateral approach provides simultaneous exposure of the anterior and posterior aspects of the spine, thereby allowing decompression of the spinal cord, posterior stabilisation and anterior and posterior bone grafting. This approach has much less morbidity than the two-stage approaches which have been previously described

Aims

To report the mid-term results of a modified self-growing rod (SGR) technique for the treatment of idiopathic and neuromuscular early-onset scoliosis (EOS).

Different methods of lateral mass(LM) screw placement in the cervical spine have been described. In the axial plane, 30 degrees is the recommended angle to avoid neurovascular injury. The estimation of this angle remains arbitrary and operator dependant. To assess how accurately the lateral trajectory angle (LTA) for cervical LM screws is achieved by visual estimation amongst experienced spinal surgeons. A sawbone model of cervical spine with simulated lordosis was used. Five spinal consultants and five senior spinal fellows were asked to insert 1.6 mm K wires into lateral masses of C3 to C6 bilaterally to simulate screws. The LTA in transverse plane was measured using a customised protractor. Basic statistical analyses of all the data were obtained. Using all the angles derived, a virtual screw trajectory was drawn in the lateral plane, on a normal axial Computerised Tomography scan of cervical spine of an anonymous patient using PACS system. The overall mean LTA for the group was 25.15 degrees, that of the fellows 24.4 and consultants 26.2 degrees. Mean deviation from 30 degrees for fellows was 5.2 and 6.4 degrees for consultants. Overall standard deviation was 4.78, for fellows and consultants it was 3.3 and 5.8 respectively. Two episodes of vertebral artery injury occurred at 15 and 16 degrees with simulated angles on CT. A moderate variability in visual estimation of the trajectory angle exists even amongst experienced surgeons during insertion of cervical LM screws. An anatomical landmark would be useful to improve the reliability of the procedure

Aims

Significant correction of an adolescent idiopathic scoliosis in the coronal plane through a posterior approach is associated with hypokyphosis. Factors such as the magnitude of the preoperative coronal curve, the use of hooks, number of levels fused, preoperative kyphosis, screw density, and rod type have all been implicated. Maintaining the normal thoracic kyphosis is important as hypokyphosis is associated with proximal junctional failure (PJF) and early onset degeneration of the spine. The aim of this study was to determine if coronal correction per se was the most relevant factor in generating hypokyphosis.

Posterior cervical wiring is commonly performed for patients with spinal instability, but has inherent risks. We report eight patients who had neurological deterioration after sublaminar or spinous process wiring of the cervical spine; four had complete injuries of the spinal cord, one had residual leg spasticity and three recovered after transient injuries. We found no relation between the degree of spinal canal encroachment and the severity of the spinal-cord injury, but in all cases neurological worsening appeared to have been caused by either sublaminar wiring or spinous process wiring which had been placed too far anteriorly. Sublaminar wiring has substantial risks and should be used only at atlantoaxial level, and then only after adequate reduction. Fluoroscopic guidance should be used when placing spinous process wires especially when the posterior spinal anatomy is abnormal

Aims

Intraoperative 3D navigation (ION) allows high accuracy to be achieved in spinal surgery, but poor workflow has prevented its widespread uptake. The technical demands on ION when used in patients with adolescent idiopathic scoliosis (AIS) are higher than for other more established indications. Lean principles have been applied to industry and to health care with good effects. While ensuring optimal accuracy of instrumentation and safety, the implementation of ION and its associated productivity was evaluated in this study for AIS surgery in order to enhance the workflow of this technique. The aim was to optimize the use of ION by the application of lean principles in AIS surgery.

Aims

To compare the rates of sagittal and coronal correction for all-pedicle screw instrumentation and hybrid instrumentation using sublaminar bands in the treatment of thoracic adolescent idiopathic scoliosis (AIS).

Aims

There is little information about the optimum number of implants to be used in the surgical treatment of idiopathic scoliosis. Retrospective analysis of prospectively collected data from the Swedish spine register was undertaken to discover whether more implants per operated vertebra (implant density) leads to a better outcome in the treatment of idiopathic scoliosis. The hypothesis was that implant density is not associated with patient-reported outcomes, the correction of the curve or the rate of reoperation.

Aims

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

Aims

The aim of this study was to compare the peak pull-out force (PPF) of pedicle-lengthening screws (PLS) and traditional pedicle screws (TPS) using instant and cyclic fatigue testing.

Aims

The aim of this study was to report a retrospective, consecutive series of patients with adolescent idiopathic scoliosis (AIS) who were treated with posterior minimally invasive surgery (MIS) with a mean follow-up of two years (sd 1.4; 0.9 to 0 3.7). Our objectives were to measure the correction of the deformity and record the peri-operative morbidity. Special attention was paid to the operating time (ORT), estimated blood loss (EBL), length of stay (LOS) and further complications.

Percutaneous placement of pedicle screws is a well-established technique, however, no studies have compared percutaneous and open placement of screws in the thoracic spine. The aim of this cadaveric study was to compare the accuracy and safety of these techniques at the thoracic spinal level. A total of 288 screws were inserted in 16 (eight cadavers, 144 screws in percutaneous and eight cadavers, 144 screws in open). Pedicle perforations and fractures were documented subsequent to wide laminectomy followed by skeletalisation of the vertebrae. The perforations were classified as grade 0: no perforation, grade 1: < 2 mm perforation, grade 2: 2 mm to 4 mm perforation and grade 3: > 4 mm perforation. In the percutaneous group, the perforation rate was 11.1% with 15 (10.4%) grade 1 and one (0.7%) grade 2 perforations. In the open group, the perforation rate was 8.3% (12 screws) and all were grade 1. This difference was not significant (p = 0.45). There were 19 (13.2%) pedicle fractures in the percutaneous group and 21 (14.6%) in the open group (p = 0.73). In summary, the safety of percutaneous fluoroscopy-guided pedicle screw placement in the thoracic spine between T4 and T12 is similar to that of the conventional open technique.

Cite this article: Bone Joint J 2015;97-B:1555–61.

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

Cite this article: Bone Joint J 2015; 97-B:1111–17.

We describe the results of a prospective case series of patients with spondylolysis, evaluating a technique of direct stabilisation of the pars interarticularis with a construct that consists of a pair of pedicle screws connected by a U-shaped modular link passing beneath the spinous process. Tightening the link to the screws compresses bone graft in the defect in the pars, providing rigid intrasegmental fixation. We have carried out this procedure on 20 patients aged between nine and 21 years with a defect of the pars at L5, confirmed on CT. The mean age of the patients was 13.9 years (9 to 21). They had a grade I or less spondylolisthesis and no evidence of intervertebral degeneration on MRI. The mean follow-up was four years (2.3 to 7.3). The patients were assessed by the Oswestry Disability Index (ODI) and a visual analogue scale (VAS). At the latest follow-up, 18 patients had an excellent clinical outcome, with a significant (p < 0.001) improvement in their ODI and VAS scores. The mean ODI score at final follow-up was 8%. Assessment of the defect by CT showed a rate of union of 80%. There were no complications involving the internal fixation.

The strength of the construct removes the need for post-operative immobilisation.

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.