A modified transthoracic approach to the thoracic vertebral column is described. In this method, the parietal pleura is detached from the chest wall and retracted with the visceral pleura and its contents. A direct approach to the vertebral bodies is thus achieved without transgression of the intrapleural space. The technique can be extended to include exposure of the thoracolumbar spinal column, utilising a thoracoabdominal approach with extrapleural and extraperitoneal dissection. Management of the costophrenic detachment is thus simplified. This approach has significant advantages for orthopaedic, vascular and neurosurgical procedures

We have performed simple bone grafting in four elderly patients with pain due to unstable pseudarthroses in the osteoporotic spine after compression fracture. At operation, we observed abnormal movement of the affected vertebral body which was covered with a hypertrophic membrane; this seemed to inhibit the blood supply to the lesion. The thick membrane and avascular granulation in the false joint were excised and bone grafting carried out. Symptoms were dramatically improved immediately after operation and bony union was confirmed in the three surviving patients

The familiar picture of spinal tuberculosis is one of destruction of adjacent vertebral bodies and of the intervening disc. There are, however, other patients without these radiographic changes and with no clinical deformity who present with symptoms and signs of compression of the spinal cord or cauda equina. These patients fall into two different groups: those with tuberculosis of the neural arch; and those with extra-osseous extradural tuberculosis. Both may require laminectomy, but whereas the first has bony involvement and a cold abscess, the second has neither

Five vertebrae with unilateral spondylolysis are presented. The associated asymmetry of the posterior elements supports the concept of a localised form of growth deficiency. The defect is difficult to demonstrate radiologically, and is perhaps present more frequently than is recognised. It should be suspected clinically from asymmetry of the neural arch and from unilateral wedging of the vertebral body, and may be demonstrated by further radiographic examination. The clinical significance is uncertain, but one patient is presented in whom unilateral spondylolysis was associated with intermittent sciatic pain

We describe two patients with an atypical congenital kyphosis in which a hypoplastic lumbar vertebral body lay in the spinal canal because of short pedicles. There were no defects in the posterior elements, or any apparent instability of the facet joints. Both patients were treated successfully by anterior fusion to the levels immediately above and below the affected vertebra, and posterior fusion which extended one level more both proximally and distally. This gave progressive correction of the kyphotic deformity by allowing some continued anterior growth at the levels which had been fused posteriorly

A thoracolumbar gibbus is an uncommon but potentially dangerous feature of achondroplasia. In a series of unselected South African Negro achondroplasts, nine out of 17 had an abnormality of this type. In contrast, only one girl out of 20 affected individuals of European or mixed ancestry had a gibbus. It is likely that the high frequency of this deformity in South African Negro achondroplasts is the result of the traditional practice by which an infant is carried on the mother's back, with the legs straddling her waist and the spine in flexion. Wedging on the vulnerable vertebral bodies in the Negro achondroplastic infant can probably be prevented by avoiding this custom

1. A case of vertebra plana (Calvé) is described and serial radiographs throughout the course of the disease are presented. 2. The initial radiographs showed a vertebra of normal depth which collapsed to a thin disc in fifteen days. Since the symptoms had begun twelve days before the first examination the total time taken to reach this stage was twenty-seven days. 3. The literature has been reviewed for evidence of the underlying pathology of vertebra plana. In the case described biopsy of the affected vertebral body was not carried out, and thus the nature of the underlying change could not be determined

1. As a result of degenerative changes in the intervertebral disc, nuclear tissue often herniates through its confining structures. These lesions are common, even in children, and often lead to difficulty in diagnosis. 2. The radiological manifestations of nuclear herniations into the spongiosa of the vertebral body, through the anterior part of the annulus fibrosus, beneath the epiphysial ring, and through the posterior part of the annulus are described and illustrated. The clinical significance of these radiological appearances and their pathological basis is indicated. 3. An understanding of the significance of the radiological findings in herniation of the nucleus pulposus and a careful correlation with the clinical features of the case are necessary for accurate diagnosis

1. Two types of spinal extradural cyst are discussed: 1) the type which occurs in adolescents in the dorsal spine with evidence of kyphosis juvenilis; 2) the type which occurs in adults in the dorso-lumbar spine without kyphosis. 2. A fifth case of dorso-lumbar spinal extradural cyst in the adult without deformity is reported. Cysts in this region present common features distinguishing them from the more frequent type which occurs in adolescents. 3. The relationship between spinal extradural cysts, venous drainage of vertebral bodies, and spinal deformity, is discussed

1. Previous studies of the movements of the lumbar spine are criticised in the light of new observations from radiograph tracings. It is shown that, contrary to recent teaching, the lumbar spine is a very mobile part of the vertebral column. 2. The movement of the lumbar spine is analysed. It is shown that the lower vertebrae have the most movement, and that the range gradually becomes less in the upper lumbar spine. 3. This movement may be roughly correlated with the incidence of spurs arising from the anterior margin of the vertebral bodies. 4. These spurs are shown to arise in the anterior longitudinal ligament; they are probably caused by intermittent pressure from the intervertebral disc lying behind the ligament

Eight patients with neurofibromatosis presented with symptoms of cervical spine involvement over a period of 17 years, five of them within the second decade of life. The symptoms included neurological deficit in five, a neck mass in four, and deformity in three; only two complained of pain. Osteolysis of vertebral bodies with kyphosis of more than 90 degrees was the most common radiological feature. Posterior fusion failed in the one patient in whom it was performed. Good results were achieved by anterior fusion, alone, or combined with posterior fusion. Surgical complications included one death in a patient with a malignant neurofibroma, and one case of transient neurological deterioration

Twelve cases of sternal injury associated with spinal fractures have been reviewed. The sternum is regularly buckled or fractured in patients with high thoracic spinal fractures. Our review suggests that sternal injuries may also be associated with spinal fractures outside this region, and with types of fracture other than crushing of vertebral bodies. Injury to the sternum, when due to indirect violence, is almost always associated with a severe spinal column injury. A displaced fracture of the thoracic spine, with or without an associated sternal fracture, can produce significant widening of the mediastinal shadow on a chest radiograph. This is caused by a paravertebral haematoma, and can be difficult to differentiate from widening due to an aortic rupture

Four infants between 2 and 13 weeks of age developed vertebral osteomyelitis. Their symptoms were different from those of children with discitis in that our patients were systemically ill, there was almost complete dissolution of involved vertebral bodies with either normal or nearly normal adjacent vertebral endplates, and three of the four children had recurrence of infection. The importance of long-term antibiotic treatment is emphasised. Years later the radiographic appearance of these children can be identical to congenital kyphosis with either anterior failure of segmentation or posterior hemivertebrae. The treatment should be the same as for congenital kyphosis with early bracing in extension and early fusion for progressive kyphosis

In 21 children with myelomeningocele who underwent kyphectomy for congenital kyphosis of the lumbar spine, aortography revealed no case in which the aorta followed the spinal curvature. Many anomalies of the intercostal and segmental arteries were demonstrated which were only in part associated with deformities of the respective vertebral bodies. The kidneys, which were frequently malformed, often lay within the kyphosis and were therefore at risk of operative damage. We conclude that the aorta is not at risk and that aortography is not usually necessary before kyphectomy, except in patients who have undergone prior abdominal surgery. Non-invasive methods (ultrasound, CT or MRI) should be used to detect malpositions and malformations of the kidneys

1. A thirty-two-year-old man has been under treatment for twelve years for primary hydatid disease of the body of the third lumbar vertebra. 2. The second lumbar vertebra became involved, as were the soft tissues over a wide area, but the spinal canal was not affected. 3. A hydatid cyst was found in the left lung. 4. Management included stabilisation of the spine by bone graft, desensitisation to hydatid antigen, removal of the diseased vertebral bodies, pedicles and processes, the use of saturated solution of sodium chloride as a scolicide and the dilation of secondary ureteral strictures. 5. The patient, although not cured, has been enabled to "live with his disease" to earn his living and enjoy tennis and swimming

1. The belief that the cessation of spinal growth and curve progression coincides with the completion of growth in the iliac apophyses has been confirmed in a review of material from 224 cases. This applies also to paralytic curves. 2. In a high number of cases this ossification centre showed an asymmetrical development on the two sides of the pelvis. The appearance of a separate posterior centre of ossification is also common, and probably represents an advanced stage in the growth of the iliac apophysis. 3. Menarche and the growth of the apophyses of the vertebral bodies almost always occurred in advance of the iliac apophyses. They should be regarded as early signs of maturation, not reliable in the prognosis of curve progression. 4. The growth of the iliac apophysis appeared to be unaffected by poliomyelitis

We reviewed 40 extensive destructive vertebral lesions in 35 patients with established ankylosing spondylitis. Of these, 31 had presented with localised pain while three had a neurological deficit. The radiographs suggested ununited fractures through either ankylosed discs (37) or vertebral bodies (3). Corresponding fractures were seen in the posterior column in 34 cases. Sixteen patients with 18 lesions underwent anterior spinal fusion, and pseudarthrosis was consistently proven by histopathology. Two pseudarthroses healed in conservatively treated patients. Thirteen of the operated patients were followed for an average of 7 years 7 months. There were two cases of non-union and one required an additional posterior fusion; in the remainder fusion was sound

Between 1969 and 1989, we performed posterior segmental instrumentation on 38 patients with thoracic Scheuermann's kyphosis. We used a dynamic system without sublaminar fixation, and a kyphosis of 50 degrees was the main indication for surgery. The mean initial angle was 68 degrees (50 to 100) and the mean final kyphosis was 43 degrees at five-year follow-up, with a mean final loss after surgery of 3.7 degrees. Reconstruction of the vertebral bodies, vertebral wedging and the anterior-body height ratio were observed even in skeletally mature patients. There were no medical complications. There were three cases of loss of correction by more than 10 degrees and one of rod fracture with pseudarthrosis. The role of non-operative treatment is evaluated and early surgical treatment is advocated

A review is presented of 13 young patients with congenital scoliosis who were treated by epiphysiodesis of part of the vertebral bodies combined with posterior fusion, both on the convex side; the plan was to arrest growth on the convexity which, combined with growth of the concave side, would result in progressive correction of the curve. The first patient was operated on at the age of four years and has now reached skeletal maturity with complete correction of her curve. Several others, still growing, are showing progressive correction. Only three curves, in which kyphosis was more severe than scoliosis, have deteriorated since operation. Although full assessment must await skeletal maturity of all the patients, this approach appears to have sufficient potential to justify an early report

Sixty patients with congenital deformities of the spine were operated upon in the past fifteen years using a two-stage procedure. In the fifty patients with scoliosis half of the deformities were due to hemivertebrae and half to unilateral bars. The average correction of the deformity was 47 per cent. Early neurological signs observed in two patients with a diastematomyelia resolved. Of the ten patients with kyphosis nine had neurological signs of impending paraplegia and one was completely paraplegic before operation; all improved markedly. Posterior spinal fusion alone in the rapidly progressing congenital deformity may not prevent further progression, particularly in those cases iwth unilateral bars. Anterior resection of the vertebral body with later posterior fusion with Harrington instrumentation is safe and effective