We describe a lumbar facet syndrome in which disabling symptoms are associated with normal or near-normal plain radiographs. Local spinal fusion relieved symptoms in 12 patients; the excised facet joint surfaces showed some of the histological changes seen in chondromalacia patellae and in osteoarthritis of other large joints. The most frequent change was focal full-thickness cartilage necrosis or loss of cartilage with exposure of subchondral bone, but osteophyte formation was remarkably absent in all specimens. We suggest that there are both clinical and histological similarities between the facet arthrosis syndrome and chondromalacia patellae. Facet arthrosis may be a relatively important cause of intractable back pain in young and middle-aged adults

The operative and anaesthesic technique for 44 patients undergoing posterior spinal fusion with Harrington rod instrumentation for idiopathic scoliosis is described. There were two groups of 21 and 23 patients, matched for diagnosis and status before operation. The management of both groups was similar but in one group anaesthesia with induced hypotension was employed, using a mixture of sodium nitroprusside and trimetaphan. The mean blood loss at operation and after operation in this group was significantly lower than in the other group, with a consequent reduction in the transfusion requirement. No adverse sequelae were observed. All patients showed a drop in haemoglobin concentration after operation, despite clinically adequate blood transfusion

Twenty-eight patients with adolescent idiopathic scoliosis treated by anterior spinal fusion with Dwyer instrumentation were reviewed. The average length of follow-up was 6.9 years. This technique produced better correction of lateral curvature and rotation than Harrington instrumentation, particularly in the thoracolumbar and lumbar region. The length of spine requiring fusion was also shorter. There is, however, a tendency for Dwyer instrumentation to lead to kyphosis. Morbidity was significant and included one case of paraplegia, four cases of deep infection and one case of instrument failure. All of these complications, except one case of deep infection, occurred in patients with curves with an apex above the seventh thoracic vertebra

A series of 98 patients with juvenile idiopathic scoliosis have been analysed. This showed that between the ages of four and six there was a higher incidence in boys whereas between seven and nine years of age, the proportion of girls was higher. Regardless of sex and age the majority of the curves were convex to the right and the single thoracic curve was the commonest pattern. Spontaneous resolution occurred in seven patients: in four the curves resolved within two years; in the three others the curves resolved in three, four and five years respectively. Forty-four per cent of all patients were managed conservatively and in 56 per cent spinal fusion was carried out

Thirteen patients with dystrophic spinal deformities from neurofibromatosis treated by anterior and posterior fusion have been reviewed. The shortest follow-up was five years, the average seven years. Combined fusion produced satisfactory results in patients with a smooth kyphoscoliosis or with scoliosis without kyphosis, but it was unsatisfactory in patients with an angular kyphoscoliosis. Of the five patients with angular kyphoscoliosis, one had a persistent pseudarthrosis after operation and all had progression of the kyphosis despite the treatment. The morbidity rate also was high in this group of patients. Many of the complications were related to soft-tissue manifestations of the disease. It is recommended that very special attention be paid to the dystrophic angular deformity in neurofibromatosis; even anterior and posterior spinal fusion may fail to control its progression

We reviewed 77 unfused and 91 fused patients with idiopathic scoliosis who first attended between 1949 and 1965. Both groups were re-examined at least 10 years after reaching skeletal maturity, with attention to progression of the Cobb angle, increased in vertebral rotation, back pain and psychosocial problems. We found that spinal fusion protects the scoliotic spine from further deterioration during adult life except for those with severe curves and marked rotation. Fusion also significantly reduced the incidence of severe pain and allowed patients to carry out heavy physical work, but did not confer complete immunity from backache. Surgery improved the appearance, but patients were not always completely satisfied with the cosmetic result

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

1. The clinical features in nineteen patients with structural defects of the pars interarticularis are compared with the findings in twenty-two patients with degenerative changes in the lumbar spine, and are shown to be essentially the same. 2. It is suggested that both structural defects and degenerative changes give rise to mechanical instability of the lumbar spine. This puts an increased load on the posterior vertebral soft tissues and gives rise to a characteristic picture, the features of which are described. 3. The signs and symptoms of root compression may be superimposed on this picture, and when this is the case, decompression of the nerve roots should be undertaken in addition to spinal fusion, which is suggested as the logical treatment. 4. After fusion, with decompression when indicated, 50 per cent of the patients were completely relieved of their symptoms and 87 per cent derived worthwhile benefit

Computer-assisted frameless stereotactic image guidance allows precise preoperative planning and intraoperative localisation of the image. It has been developed and tested in the laboratory. We evaluated the efficacy, clinical results and complications of placement of a pedicle screw in the lumbar spine using this technique. A total of 62 patients (28 men, 34 women) had lumbar decompression and spinal fusion with segmental pedicle screws. Postoperative CT scans were taken of 35 patients to investigate the placement of 330 screws. None showed penetration of the medial or inferior wall of a pedicle. Registration was carried out 66 times. The number of fiducial points used on each registration averaged 5.8 (4 to 7) The mean registration error was 0.75 mm (0.32 to 1.72). This technique provides a safe and reliable guide for placement of transpedicular screws in the lumbar spine

The results of treatment of injuries of the thoracic and thoraco-lumbar spine with neurological involvement have been reviewed in a retrospective study of 115 patients, of whom eighty-nine received conservative and twenty-six surgical treatment. Operation was reserved, in general, for patients with irreducible dislocations and incomplete neurological lesions, open reduction and internal fixation being the commonest procedure. Only three patients required a delayed spinal fusion for suspected instability after a period of conservative treatment. On the other hand, ten patients, eight of whom had been treated surgically, were left with severe chronic spinal pain. Of the patients treated conservatively, 35% showed significant neurological improvement compared to 38% of those treated surgically, but the latter group contained a much higher proportion of incomplete lesions with a far better prognosis. It is concluded that the place for early operation might be still further restricted

We performed a randomised, controlled clinical trial to compare ambulant short-course chemotherapy with anterior spinal fusion plus short-course chemotherapy for spinal tuberculosis without paraplegia. Patients with active disease of vertebral bodies were randomly allocated to one of three regimens: a) radical anterior resection with bone grafting plus six months of daily isoniazid plus rifampicin (Rad6); b) ambulant chemotherapy for six months with daily isoniazid plus rifampicin (Amb6); or c) similar to b) but with chemotherapy for nine months (Amb9). Ten years from the onset of treatment, 90% of 78 Rad6, 94% of 78 Amb6 and 99% of 79 Amb9 patients had a favourable status. Ambulant chemotherapy for a period of six months with daily isoniazid plus rifampicin (Amb6) was an effective treatment for spinal tuberculosis except in patients aged less than 15 years with an initial angle of kyphosis of more than 30° whose kyphosis increased substantially

We classified fixed pelvic obliquity in patients after poliomyelitis into two major types according to the level of the pelvis relative to the short leg. Each type was then divided into four subtypes according to the direction and severity of the scoliosis. In 46 patients with type-I deformity the pelvis was lower and in nine with type II it was higher on the short-leg side. Subtype-A deformity was a straight spine with a compensatory angulation at the lower lumbar level, mainly at L4-L5, subtype B was a mild scoliosis with the convexity to the short-leg side, subtype C was a mild scoliosis with the convexity opposite the short-leg side, and subtype D was a moderate to severe paralytic scoliosis with the convexity to the short-leg side in type I and to the opposite side in type II. A combination of surgical procedures improved the obliquity in most patients. These included lumbodorsal fasciotomy, abductor fasciotomy and stabilisation of the hip by triple innominate osteotomy with or without transiliac lengthening. In patients with type ID or type IID appropriate spinal fusion was usually necessary

Bone-marrow transplantation has increased the survival of patients with mucopolysaccharidosis-I. We describe the spinal problems and their management in 12 patients with this disorder who have been followed up for a mean of 4.5 years since transplantation. High lumbar kyphosis was seen in ten patients which was associated with thoracic scoliosis in one. Isolated thoracic scoliosis was seen in another. One patient did not have any significant problems in the thoracic or lumbar spine but had odontoid hypoplasia, which was also seen in three other children. Four of the eight patients in whom MRI of the cervical spine had been performed had abnormal soft tissue around the tip of the odontoid. Neurological problems were seen in two patients. In one it was caused by cord compression in the lower dorsal spine 9.5 years after posterior spinal fusion for progressive kyphosis, and in the other by angular kyphosis with thecal indentation in the high thoracic spine associated with symptoms of spinal claudication

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).

The factors during and after operation which influence the development of a solid and stable posterior spinal fusion have been evaluated in 406 patients with scoliosis. The patients were managed in three different ways and all pseudarthroses were accurately detected by exploring the spines six months after the attempted fusion. The incidence of pseudarthroses was significantly lowered from 25 per cent in Group I to 3.8 per cent in Group III by the application of Harrington instrumentation and the use of large amounts of autogenous iliac bone grafts in addition to an interfacetal fusion. Early mobilisation 7 to 10 days after operation and a return to normal activities in a well-moulded underarm plaster jacket did not have a detrimental effect on the development of the fusion or the early maintenance of correction. Those spines with supplementary bone grafts stabilised more rapidly and had better maintenance of correction with only minimal loss after removal of all external support at 10 months

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

We analysed the complications encountered in 102 consecutive patients who had posterolateral lumbosacral fusion performed with transpedicular screw and rod fixation for non-traumatic disorders after a minimum of two years. Of these, 40 had spondylolysis and spondylolisthesis, 42 a degenerative disorder, 14 instability after previous laminectomy and decompression, and six pain after nonunion of previous attempts at spinal fusion without internal fixation. There were 75 multilevel and 27 single-level fusions. There were 76 individual complications in 48 patients, and none in the other 54. The complications seen were screw misplacement, coupling failure of the device, wound infection, nonunion, permanent neural injury, and loosening, bending and breakage of screws. Screw breakage or loosening was more common in patients with multilevel fusions (p < 0.001). Screws of 5 mm diameter should not be used for sacral fixation. Forty-six patients had at least one further operation for one or several complications, including 20 fusion procedures for nonunion. The high incidence of complications is a disadvantage of this technically-demanding method

We present a study of ten consecutive patients who underwent excision of thoracic or thoracolumbar hemivertebrae for either angular deformity in the coronal plane, or both coronal and sagittal deformity. Vertebral excision was carried out anteriorly alone in two patients. Seven patients had undergone previous posterior spinal fusion. Their mean age at surgery was 13.4 years (6 to 19). The mean follow-up was 78.5 months (20 to 180). The results were evaluated by radiological review of the preoperative, postoperative and most recent follow-up films. The mean preoperative coronal curve was 78.2° (30 to 115) and was corrected to 33.9° (7 to 58) postoperatively, a mean correction of 59%. Preoperative coronal decompensation of 35 mm was improved to 11 mm postoperatively. Seven patients had significant coronal decompensation preoperatively, which was corrected to a physiological range postoperatively. There were no major complications and no neurological damage. We have shown that resection of thoracic and thoracolumbar hemivertebrae can be performed safely, without undue risk of neurological compromise, in experienced hands

Aims

The aetiologies of common degenerative spine, hip, and knee pathologies are still not completely understood. Mechanical theories have suggested that those diseases are related to sagittal pelvic morphology and spinopelvic-femoral dynamics. The link between the most widely used parameter for sagittal pelvic morphology, pelvic incidence (PI), and the onset of degenerative lumbar, hip, and knee pathologies has not been studied in a large-scale setting.

Aims

While previously underappreciated, factors related to the spine contribute substantially to the risk of dislocation following total hip arthroplasty (THA). These factors must be taken into consideration during preoperative planning for revision THA due to recurrent instability. We developed a protocol to assess the functional position of the spine, the significance of these findings, and how to address different pathologies at the time of revision THA.