Objective: To assess the correlation between the side of the annular pathology and the radicular symptoms, in the absence of a compressive root lesion.

Materials and Methods: 121 patients underwent MRI scan fro axial back and radicular symptoms. The mean age was 49.9 yrs (24–80). The sex distribution was equal. We excluded the patients that had a compressive lesion, previous operations, spinal deformity, spondylolyses, an underlying pathology (tumour, trauma or infection) or a peripheral neuropathy. Annular pathology was documented as annular tear or a non-compressive disc bulge with its location and side. We also recorded marrow endplate changes and facet arthrosis.

Results: Bilateral radicular symptoms were reported in 16 (13.2%): right side in 33 (27.3%) and left in 47 (38.8%) patients. Additionally, 82 patients (67.8%) had axial back pain. 33 patients (27.3%) were noted to have a right sided annular pathology (tear or bulge) and 72 (59.5%) had a left sided annular lesion. 21 patients (17.4%) had a central annular tear and 43 (35.5%) had a generalised disc bulge. 14 patients (11.6%) with right sided symptoms also had annular pathology, while 38 patients (31.4%) with left sided symptoms had a left sided annular lesion. There was no statistical correlation between the side of symptoms and the side of the lesion (r = −0.00066, p=0.994), any particular annular pathology (annular tear r=0.085, p=0.35; disc bulge r-0.083, p=0.36). There was no correlation between the axial back pain and the annular pathology (r=0.004; p=0.97) and facet joint or marrow end plate changes (r= −,29, p=0.76).

Conclusions: Although annular pathology can cause the radicular symptoms, our results suggest that they do not influence the side of the symptoms.

In the last few decades pedicle screw placement has brought in a genuine scientific revolution in the surgical care of spinal disorders. The technique has dramatically improved the outcomes of spinal reconstruction requiring spinal fusion. Short segment surgical treatments based on the use of pedicle screws for the treatment of neoplastic, developmental, congenital, traumatic and degenerative conditions have been proved to be practical, safe and effective.

The reported incidence of nerve root damage after the use of pedicle screws ranges from 2% to 32%. The utilization of computerized image-guided technology in lumbosacral spinal fusion surgery offers increased accuracy of pedicle screw placement. We decided to review our x-rays of pedicle screw placement, and to assess the percentage misplacement of pedicle screws inserted without computer assistance. This is a retrospective study and our results are compared with those in the literature.

80 Post operative radiographs of patients operated on for trauma and degenerative conditions of the thoracolumbar spine were studied. Initially these were looked at independently by 2 orthopaedic spinal surgeons and a radiologist, and subsequently all x-rays were reviewed together to see where consensus could be reached where there was any disagreement.

The percentage of misplaced screws inserted under fluoroscopy was obtained, and compared to the percentage of misplaced screws inserted under image guidance reported in the literature. Our study shows that there is no significant difference between the 2 techniques.

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 lumbar spine consists of a mobile segment of 5 vertebrae, which are located between the relatively immobile segments of the thoracic and sacral segments. The bodies are wider and have shorter and heavier pedicles, and the transverse processes project somewhat more laterally and ventrally than other spinal segments. The laminae are shorter vertically than are the bodies and are bridged by strong ligaments. The spinous processes are broader and stronger than are those in the thoracic and cervical spine.

Internal fixation as an adjunct to spinal fusion has become increasingly popular in recent years. Stainless steel or titanium plates or rods are longitudinally anchored to the spine by hooks or pedicle screws. Powerful forces can be applied to the spine through these implants to correct deformity. Implants provide immediate rigid spinal immobilization, which allows for early patient mobilization, and provides a more optimal environment for bone graft incorporation. Numerous clinical and experimental studies demonstrate higher fusion rates in patients with rigid internal fixation than in controls without instrumentation. Although various implants are available, pedicle fixation systems are the most commonly used implant type in the lumbosacral spine. The large size of the lumbar pedicles minimizes the number of instrumented motion segments required to achieve adequate stabilization.

Many authors have reported loss of postoperative deformity correction after transpedicular screw fixation, ranging from 2.5 degrees to 7.1 degrees. The general preference is to stabilize the fractured vertebra by fusing one level above and one level below. With this technique, the rate of loss of correction is high. At our institution, we routinely stabilize the unstable thoracolumbar fractures by fusing one level above and one level below. In addition, we put screws into the pedicle(s) of fractured vertebrae. The reason for this is the following:

To correct the deformed body of the fractured vertebra for better load sharing.

Plain radiographs were analysed post operatively and compared for reduction of the fracture fragments and correction of kyphotic deformity to pre-operative films. 74 Patients were admitted with thoracolumbar spine fractures to our hospital. 48 Patients were surgically treated, and 34 patients were available for follow up. We found that inserting the pedicle screws into the fractured vertebra provided good stabilization for very unstable fractures. No loss of correction was seen in the follow up x-rays. We conclude that including the fractured vertebra into the fracture fixation device not only provides better fracture reduction, but also gives improved rotatory stability.

Background data: The Paediatric Isola system uses the philosophy of torsion-countertorsion force as a means of scoliosis correction. It aims to maintain this correction till such time that definitive fusion can be carried out.

Aim: This is a retrospective case series of our experience with the Paediatric Isola system and we evaluated the results of this system in the treatment of Scoliosis of various etiologies.

Methods: Twenty –one children,5 with neuromuscular,1 with Ehler-Danlos,5 with idiopathic,3 syndromic and 7 congenital treated with the Isola Instrumentation were studied.

Average age was 6.5 years(2–12). Average follow-up was 24 months (6m-36m).

Results: The average Cobb angle was 52° before surgery, 33.7° after surgery (64 % correction) and 32.5° (62.5% correction) at latest follow-up. The mean apical vertebral translation was 86% and 84% at post-op and latest follow-up. Stabilisation was most commonly perfomed from T2 to L4/L5. Three patients had implant complications, two had deep seated wound infections which necesssiated removal of implants in one case. Five of these patients have gone on to definitive fusions. Curve correction was best for primary thoracolumbar curves and lumbar curves. 2 patients with thoracic curves did not maintain correction.

Conclusion: The Paediatric Isola system is a safe and effective instrumentation in early management of a difficult and challenging sub group of scoliosis patients.

Purpose: We describe a technique using orthoganol imaging on a radiolucent table that allows reliable, safe and reproducible insertion of thoracic pedicle screws.

Method: The popularity of pedicle screws for spinal fixation in deformity surgery has increased. Studies have shown lumbar pedicle screws to be safe and effective. The biomechanical superiority of pedicle screws has also been demonstrated. Nonetheless, reluctance to apply the technique to thoracic vertebra remains, most likely because of perceived technical difficulties and a reported high complication rate.

We describe a technique using orthoganol imaging on a radiolucent table, used in a series of patients in whom we have inserted a total of over 2000 screws.

Results: We have inserted over 2000 thoracic pedicle screws without neurological injury. In addition, this technique has allowed us to use pedicle screw to the exclusion of other, less mechanically favourable, methods of fixation to the spine; over the same time period we used only three sublaminar hooks.

Furthermore, the lateral to medial or ‘toeing in’ of screw placement gives greater pull out strength to each screw by increasing the ‘volume’ of bone that has to be overcome before failure by pull out occurs. In addition this trangulation technique allows insertion of :screws of greater diameter than the pedicle and decreases the chance of broaching medially.

Conclusion: Using the technique described, we achieve accurate screw placement ‘first time, every time’, giving us a biomechanically superior construct, allowing more powerful derotation of the spine and thus greater correction of deformity. We recommend its use for all thoracic pedicle screws.

Purpose: We report our surgical management of a series of primary and metastatic tumours of the lumbosacral junction, highlighting different methods of fixation, outcome and complications.

Method: Seven patients with primary and four with secondary tumours involving the lumbosacral junction underwent surgery. After tumour resection, iliolumbar fixation was performed in all but one case, using Galveston rods (4) or iliac screws (6). All constructs were attached proximally with pedicle screws. Cross links were used in all instrumented cases and autologous and allogenic bone graft applied.

Results: There were no perioperative deaths. Mean operating time was 7.3 hours (range 3–18) and there was extensive blood loss (mean transfusion requirement 7.5 units, range 0–20). We estimate a transfusion requirement of approximately one unit per hour operating time. However, we noted no complications attributable to either blood loss or transfusions.

Ambulation improved in 5, was unchanged in 5 and deteriorated in one. Neurological status deteriorated in 4 and remained static in the others. However in all but one case the neurological deficit was defined by the nature of proposed surgery. Mean survival from surgery for patients with metastatic disease was 9.5 months (3–18). At mean follow up of 10 months (1–19 months), all patients with primary tumours were still alive without evidence tumour recurrence.

Extralesional excision, and therefore potentially curative surgery, was achieved in 4 cases where this was the primary goal of surgery (osteosarcoma, osteoblastoma, chordoma, embryonic rhabdomyosarcoma). There were no cases of metalwork failure. One patient has undergone revision surgery for pseudathrosis.

Conclusion: Sacral resection and iliolumbar reconstruction is a feasible treatment option in selected patients, offering potential cure. The fixation methods used by the authors restored lumbosacral stability, sufficient for pain relief and preserving ambulation and usually the predicted level of neurological function.

The Ilizarov technique of distraction osteogenesis is becoming a more common way of treating complicated fractures. It has been shown that shear IFMs will delay bone healing whilst axial IFMs are beneficial to the bone healing. Therefore to measure IFMs in conditions of mobility will provide critical information for research and clinic diagnosis. Such data are not provided by static measurements. Traditionally the IFMs were measured by implanting transducers to the bone or using radiological methods. However, these methods are not suitable for either clinic utilization or measurement of IFMS when patients are doing movements which simulate their daily activities. We have designed a dynamic IFMs measuring device.

It includes a displacement transducer array, which is connected to the Ilizarov wires. This transducer array consists of 6 parallel linear displacement transducers, each of which is attached to the fixing wires of the fix-ator. This arrangement of transducers can fit into the configuration of Stewart Platform. The Reverse Stewart Platform algorithm was employed to calculate IFMs. Without measuring the bone fracture segments directly, the two segments were fitted into two planes virtually. By studying the relative movements of the two virtual planes, the algorithm transfers the relative movement to relative axial & shear translation, and relative bending & torsion rotation, between the two fracture segments. Wireless interface was used to transfer the displacement readings from the transducer array to the computer. This setup allows patient perform activities which represent their routine activities.

In laboratory studies, we found the error of this system to be related to the IFMs. For small movements around 100 micron, the absolute error was 50 micron, whereas for larger movements around 1 mm, the error was within 0.22mm.

This real time monitoring method will allow kinematical and kinetic studies on fracture patients treated with Ilizarov frame. Measurements obtained using this novel device will reflect the natural pattern of IFMs during the patients’ daily life. Since use of the device requires no additional pin, wire or operative procedure, it will be clinically applicable. The accurate real-time IFMs measurements will help elucidate the complex interplay between movement and bone formation.

Back pain is a major cause of disability and absence from work. 80% of the population will experience back pain at some point in their lives. In our study we looked at 2 randomised groups of patients. Group 1 patients had only epidural steroid injections (ESI) and group 2 patients had ESI plus radiofrequency (RF). We hypothesized that there is no difference in outcome between group 1 and 2 patients. The 2 groups were sent out a retrospective questionnaire which had 5 parts to it, including SF-36 health survey, pain drawing chart, visual analogue scale (VAS), oswestry disability score (ODS) and a patient satisfaction questionnaire. The patients had treatment between 2002 and 2003 and the post-treatment questionnaires were sent out in May 2004. The SF-36 was scored giving a physical component score (PCS) and a mental component score (MCS) using an online scoring website. The groups studied were from 2 different referral hospitals. The patients were randomised by GP referral being sent to the 2 different hospitals. 115 questionnaires with stamped addressed envelopes were sent out to group 1 patients, out of which 71 were returned (61.7%) and 113 to group 2 patients out of which 55 were returned (48.7%). Statistical analysis was done using the SPSS software programme. As there was some evidence of non-normality Mann-Whitney test was carried out, and for the patient satisfaction questionnaire, chi-squared and fisher’s exact test was used. We found that there was a significant difference among the 2 groups in the PCS (p< 0.0005) and MCS (p=0.017). There was a statistically significant difference among the 2 groups in their pain draw score, VAS and ODS with p values of < 0.0005. In the patient satisfaction questionnaire, 8 questions were asked. Patients were asked to assess how successful the spinal injection was. 35 (67%) patients from group 2 said it was successful, compared with 25 (37%) patients from group 1. 9 (17%) patients from group 2 said it was not successful compared with 27 (40%) patients from group 1. 8 (15%) patients were not sure from group 2 and 16 (24%) were not sure from group 1. The difference was statistically significant with a p value of 0.003. When asked whether they would recommend this type of injection, more patients from group 2 said they would (p=0.029). When asked about the duration of effectiveness of the injection, group 2 noticed an increased duration of benefit compared with group 1 (p< 0.0005). There was no significant difference between the groups when asked how many injections were required (p=0.089) or when asked whether or not they required painkillers (p=0.062). However, more patients from group 2 said that painkillers controlled their pain (p=0.001). When asked if they were able to return to work and do housework/gardening after injection, there were significantly more patients from group 2 being able to do so (p< 0.0005). We conclude that in the patients studied, the group who had radiofrequency treatment and epidural steroid injection did better as compared with patients who had epidural steroid injection alone.

Personal injury claims following whiplash injury currently cost the British economy more than £3 billion a year, yet only a minority of patients have radiologically demonstrable pathology. Patients sustaining fractures of the cervical spine have been subjected to greater force and might reasonably be expected to have worse symptoms than those with whiplash injuries.

Using the Neck Disability Index, we compared pain and functional disability in four groups of patients who had suffered cervical spine injuries. The four groups were: patients with stable cervical fractures treated conservatively, patients with unstable cervical fractures treated by internal fixation, patients with whiplash injuries seeking compensation, and patients with whiplash injuries not involved in litigation.

After a mean follow-up of 3½ years, patients who had sustained cervical spine fractures had significantly lower levels of pain and disability than those who suffered whiplash injuries and were pursuing compensation (p< 0.01), but had similar level to those whiplash sufferers who had settled litigation or had never sought compensation.

Functional recovery following neck injury is unrelated to the physical insult. The increased morbidity in whiplash patients is likely to be psychological and is associated with litigation.

Traditionally clubfoot in South Africa is treated by manipulation, serial casting and, at the age of 3 to 4 months, posteromedial release. Revision surgery, with its attendant problems, is often necessary.

In November 2003 we started using the Ponseti technique. To date we have treated 61 feet, most of which are type-III according to the Harold and Walker classification. Serial castings are done according to Ponseti technique. Initially the forefoot is manipulated into supination to align it with the hindfoot. The talonavicular joint is gradually reduced until 75° of abduction is achieved. Then percutaneous tenotomy is done to correct hindfoot equinus. Manipulation is done weekly and an above-knee cast is applied. Following tenotomy, the cast remains in place for 3 weeks, after which a Denis Brown splint is worn continually (except at bath time) for 3 months and then at night for 3 years. Parent compliance has been good.

We have had six failures to date. One foot was found to have tarsal coalition and another was an arthrogrypotic foot, which was successfully corrected.

Our results suggest that most operations for clubfoot are avoidable. The Ponseti manipulation technique is simple and can easily be taught to the staff of peripheral hospitals, making it ideal for treatment of clubfoot in Africa.

Aims: The purpose of this study was to investigate the number and type of complications following external þxation of pelvic fractures. Methods: We carried out a retrospective review of all patients treated at Frenchay Hospital with external þxation for fractures of the pelvic ring between August 1996 and September 2002. Patientsñ details were collected prospectively; outcome data was collected by casenote review. Results: 74 patients were treated with external þxation for pelvic fractures. In 41 patients, the þxator was used to achieve pelvic stability temporarily, whilst in 33 it was retained as part or all of the deþnitive treatment. 30 patients were haemodynamically unstable when the þxator was applied. Of these patients, two patients died of retroperitoneal haemorrhage, three had pelvic angiography and arterial embolisation and þve required a laparotomy, of which three were negative. Of the þxators used temporarily, four (10%) had pin-site infections. In only one case did this change the plan for the deþnitive treatment. Two of the temporary þxators required revision; one for loss of reduction secondary to pin loosening and one for pin penetration of the femoral head after using the low anterior approach. Six (8%) of all the þxators required repositioning due to impingement on the skin. Of the deþnitive þxators, 53% required antibiotics and 18% required pin removal for sepsis. Three (9%) of the deþnitive þxators required revision; there was one loss of reduction, one re-displacement after removal and one non-union of the pelvic fractures. Conclusions: Temporary application of external þxation to the fractured pelvis, using high iliac crest pin placement to restore pelvic stability, is a safe procedure with few complications. Haemodynamic stability is restored in the majority of patients. When used as part of the deþnitive treatment, pin site infection is common and may require pin removal but rarely leads to loss of fracture reduction or revision of þxation.

Nitric oxide (NO) is a free radical labile gas which has important physiological functions and is synthesised by the action of a group of enzymes called nitric oxide synthases (NOS) on L- arginine. We have shown that nitric oxide modulates fracture healing¹. Bone morphogenic proteins (BMP) are potent differentiating factors that augment the process of new bone formation. Recombinant human BMP-2 (rhBMP-2) enhances spinal fusion². With progression of fusion there is a remodelling of the fusion mass bone accompanied with a decrease in the fusion mass size. It is not known whether nitric oxide has a role in spinal fusion or rhBMP-2 enhanced spinal fusion.

We studied this in a novel rat intertransverse fusion model using a defined volume of bone graft (7 caudal vertebrae) along with 157 mm3 of absorbable Type-1 collagen sponge (Helistat®) carrier, which was compacted and delivered using a custom jig for achieving a similar graft density from sample to sample. The control groups consisted of a sham operated group (S, n=20), an autograft + carrier group (AC, n=28) and a group consisting of 43 μg of rhBMP-2 (Genetics Institute, Andover, MA) mixed with autograft + carrier (ACB, n=28). Two experimental groups received a nitric oxide synthase (NOS) inhibitor, N^G-nitro L-arginine methyl ester (L-NAME, Sigma Chemicals, St Louis, MO) in a dose of 1 mg/ml ad lib in the drinking water (ACL, n=28) and one of these experimental groups had rhBMP-2 added to the graft mixture at the time of surgery (ACLB, n=28). Rats were sacrificed at 22 days and 44 days, spinal columns dissected and subjected to high density radiology (faxitron) and decalcified histology. The faxitrons were subjected to image analysis (MetaMorph).

On a radiographic score (0–4) indicating progressive maturation of bone fusion mass, no difference was found between the AC and ACL groups, however, there was a significant enhancement of fusion when rhBMP-2 was added (ACB group, 3.3±0.2) when compared to the AC group (1±0) (p< .001). However, on day 44, the ACLB group (3.3±0.2) showed significantly less fusion progression when compared to the ACB group (4±0) (p< 0.01). There was a 25% (p< 0.05) more fusion-mass-area in day 44 of ACLB group (297±26 mm³) when compared to day 44 of the ACB group (225±16 mm³) indicating that NOS inhibition delayed the remodelling of the fusion mass. Undecalcified histology demonstrated that there was a delay in graft incorporation whenever NOS was inhibited (ACL and ACLB groups).

Our results show that the biology of autograft spinal fusion and rhBMP-2 enhanced spinal fusion can be potentially manipulated by nitric oxide pathways.

Gunshot injuries to large joints are increasing in South Africa. If the bullet is in contact with the synovial fluid of the joint, it must be removed to prevent a foreign body effect and lead poisoning.

We devised a new extra-articular approach to removing the bullet from the joint. We used a reamer to make a tract in the bone towards the joint, and then removed the bullet and irrigated the joint through the same tract. Postoperatively patients were mobilised immediately. At follow-up they had good functional outcome.

Of 586 employed patients with a whiplash injury 40 (7%) did not return to work. The risk was increased by three times in heavy manual workers, two and a half times in patients with prior psychological symptoms and doubled for each increase of grade of disability. The length of time off work doubled in patients with a psychological history and trebled for each increase in grade of disability. The self-employed were half as likely to take time off work, but recovered significantly more slowly than employees.