Aims

The aim of this study was to determine whether there is an increased prevalence of scoliosis in patients who have suffered from a haematopoietic malignancy in childhood.

Purpose of study

The aim of this study was to identify the incidence of Gram negative bacterial vertebral osteomyelitis (VO) within our unit during a 3-year study period and evaluate if this corresponds to published evidence that the occurrence is increasing.

To investigate and compare the biomechanical characteristics of Bipedicular versus Unipedicular Vertebroplasty in cadaveric vertebra

Cadaveric single level vertebra were used to evaluate Bipedicular versus Unipedicular Vertebroplasty as an intervention for vertebral compression fractures

Cadaveric vertebra were assigned to two arms: Arm A simulated a wedge fracture followed by bipedicular cement augmentation; Arm B simulated a wedge fracture followed by unipedicular cement augmentation. Micro-CT imaging was performed to assess vertebral dimension, cement fill volumes and bone mineral density. All augmented specimens were then compressed under a static eccentric flexion load to failure.

Pre and post augmentation failure load and stiffness were used to compare the two groups.

Results suggest, when compared with actual failure strength, that the product of bone mineral density and endplate surface area gave a good prediction of failure strength for specimens in both arms. The mean cement volume fill of augmented vertebral bodies was 22.8% ± 7.21%. The bipedicular group showed a reduction in stiffness but an increase in post augmentation failure load of 1.09. The unipedicular group also showed a reduction in stiffness but showed a much greater increase in post augmentation failure load of 1.68.

Preliminary data from this study suggests there is a significant reduction in stiffness following both bipedicular and unipedicular vertebroplasty. There is a significant increase in failure load post augmentation in the unipedicular group.

To evaluate the efficacy of Vacuum Assisted Closure (VAC) in the management of post surgical spinal sepsis.

A retrospective analysis was performed of patients with severe post operative spinal wound infections treated using a combination surgical debridement, antibiotics and VAC therapy.

Full records were available for a total of twenty adult all of whom had had prior thoracic or lumbar instrumentation. Comorbidities included disseminated carcinomatosis (25 % of patients), Ankylosing spondylitis (5 %), rheumatoid arthritis (5%) and Polio (5%). In one patient there had been a prior history of irradiation of the surgical field. Most infections treated by this regime were identified within two weeks following surgery. At surgery infection deep to the dorso-lumbar fascia was found in 87 % of cases. It was possible to retain instrumentation in 60 % of cases. An average of three trips to theatre were required prior to wound closure, which was possible in 95 % of cases. The VAC device was left in situ for an average of 11 days. Complications included recurrence of infection necessitating further treatment in 20 % of cases, wound dehiscence necessitating healing by secondary intention in 5%, the need for free flap wound cover in 5 % and death from unrelated causes in 5%.

VAC therapy may facilitate the management of wound sepsis following spinal surgery in susceptible patients allowing the maintenance of instrumentation and surgical correction.

To determine the current practice of scoliosis surgery in the UK.

A 10 point questionnaire was constructed to identify the philosophy of surgeons on various aspects of scoliosis surgery such as choice of implant, bone graft, autologous blood transfusion (ABT), cord monitoring and computer assisted surgery. Results are compared with the current best evidence.

Consultants and Fellows attending the 2009 British Scoliosis Society meeting. 50 questionnaires were completed: 45 Consultants and 5 Fellows.

All pedicle screw construct favored by 25/50, hybrid 24/50 (one undecided). Posterior construct of less than 10 levels, 20/50 would not cross-link, 11/50 used one and 19/20 used two or more. More than ten levels 17/50 considered cross-links unnecessary, 4/50 used one and 29/50 used two or more. 88% preferred titanium alloy implants, while a mixture of stainless steel and cobalt chrome was used by others. For bone graft, substitutes (24), iliac crest (14), allograft (12) and demineralised bone matrix (9) in addition to local bone. 10/50 would use recombinant bone morphogenetic protein (3 for revision cases only). 39/50 routinely used intra-operative cell salvage or ABT drains and 4/50 never used autologous blood. All used cord monitoring, Sensory (19/50), Motor (2/50) and combined (29/50). None used computer-aided surgery. 26 operated alone 12 operated in pairs and 12 varied depending on type of case.

This survey has brought to light interesting variations in scoliosis surgery in UK. It may reflect the conflicting evidence in the literature.

Purpose of the study: To investigate whether autologous blood transfusion (ABT) drains and peri-operative cell salvage reduce allogeneic transfusion requirements for scoliosis surgery in our unit.

Methods: Prospective data collection on transfusion requirements of patients undergoing scoliosis surgery between January 2006 and February 2008. Cases were split into three groups, representing recent stepwise changes in transfusion practice. Group A received ‘traditional treatment’ of allogeneic red cell transfusion (ARCT) in response to intra- or post-operative anaemia (Hb< 8g/dL or symptomatic anaemia). Group B received peri-operative cell salvage in addition to ‘traditional treatment’. In group C, ABT wound drains were used alongside peri-operative cell salvage and ‘traditional treatment’.

Results: ARCT was required for 23 of the 35 procedures (66%) in group A, 22 of 37 (59%) in group B and 10 of 20 (50%) in group C. Where patients required ARCT, those in group C received fewer units (mean 2.6) than group B (mean 3.1) and group A (mean 3.7). There was no difference in mean preoperative haemoglobin levels (A – 13.56g/dL SD 1.36; B – 13.35g/dL SD 1.46; C – 13.94g/dL SD 1.25). Mean length of inpatient stay was lowest in group C (9.11 days), and lower in group B (12.02) than group A (13.75).

Conclusion: Use of ABT drains and peri-operative cell salvage lead to reduced allogeneic transfusion needs for scoliosis surgery in our unit. Lowest transfusion rates were seen when both were used together, leading to a 16% reduction in the need for ARCT.

Ethics approval: None

Interest Statement: None

The spinal manifestations of neurofibromatosis include cervicothoracic kyphosis, in which scalloping of the vertebral body and erosion of the pedicles may render conventional techniques of fixation impossible. We describe a case of cervicothoracic kyphosis managed operatively with a vascularised fibular graft anteriorly across the apex of the kyphus, followed by a long posterior construct using translaminar screws, which allow segmental fixation in vertebral bodies where placement of the pedicle screws was impracticable.

Abstract: It is known that the treatment of intra or extraspinal paediatric tumours with surgery and radiotherapy or radiotherapy alone can lead to the onset of progressive spinal deformity the management of which can be extremely challenging. We review our series of patients who have developed a spinal deformity in these circumstances.

Methods: A review of all patients seen between 1996 and 2007 in the spinal department who have developed a significant spinal deformity following treatment for an intra or extra spinal tumour.

Results: 14 patients were identified. The age of presentation to the spinal service was between 2 years 6 months and 15 years 3 months. The underlying diagnoses were Wilms Tumour treated with surgery and radiotherapy in 3, 1 extraspinal sarcoma treated with surgical resection, radiotherapy and chemotherapy, 1 extraspinal neuro-blastoma treated with surgery, radiotherapy, chemotherapy and stem cell rescue and 9 intra spinal tumours (PNET, astrocytoma, ganglioneuroblastoma and der-moid) all managed with resection with or without radiotherapy. The spinal deformities that have developed were thoracic kyphoscoliosis, thoracolumbar kyphosis and lumber hyperlordosis. The spinal management of these deformities has been conservative in 12 with regular assessment to allow intervention if indicated. 2 patients have undergone surgery, a vascularised fibular strut graft and anterior instrumentation in 1 and a non vascularised rib graft in 1 for progressive deformity felt to lead to neurological dysfunction or lung hypoplasia. The cases managed operatively were complicated by poor posterior soft tissues following previous surgery and radiotherapy requiring an anterior approach. In all patients who were treated with radiotherapy platyspondyly was always seen in the vertebral bodies anteriorly and this corresponded to the apex of the deformity.

Conclusion: In all children who undergo spinal surgery and or radiotherapy for paediatric tumours there must be ongoing surveillance for the development of a spinal deformity. We feel that this is as much a result of anterior growth arrest secondary to radiotherapy as to posterior laminectomy for intra canal tumour excision. The surgical management of this problem is complex and may require innovative solutions.

Introduction: The natural history of scoliosis in the presence of a cord syrinx, either treated conservatively, or post surgically, is disputed. It is generally believed to be associated with a greater likelihood of rapid deformity progression pre-operatively and a much greater likelihood of intraoperative neural injury.

In this study we aimed to retrospectively assess the local experience by reviewing patients, treated over the last 10 years, in whom scoliosis has been established, by means of MR imaging, to be associated with a cord syrinx.

Methods: A retrospective cohort study was undertaken of paediatric patients attending the Leeds Spinal Unit between the years of 1997 and 2007. The entry criteria for this study were spinal deformity with MRI proven cord syrinx, in a patient without underlying tumour or other cord anomaly. Given the association with Chiari malformation this was a measured parameter rather than exclusion criteria. Other parameters assessed were mode of presentation, progression of scoliosis, details of the identified syrinx, chosen mode of treatment for the syrinx and the scoliosis (including conservative) and outcome measures (neurological function and sequelae, change in Cobb angle/deformity correction).

Results: A total of 46 patients were identified with scoliosis and an associated syrinx. The age range was from 3 to 18 years. Only 12 were male. The syrinx was associated with an Arnold Chiari malformation in 24% of patients, and located at the apex of, or local to, the maximum deformity in 73%.

The syrinx was treated surgically in 10 patients, with 80% of these achieving either deformity arrest, or no longer requiring surgical deformity correction. In the 2 patients from the same subset who did undergo deformity correction there was no neurological sequelae. Of the conservatively managed syrinxes, deformity correction with intraoperative cord monitoring was nevertheless undertaken in 31%, all without neurological sequelae. In just 4 patients (of 69%) who did not proceed to deformity correction, surgery was precluded by the inherent risks in the presence of an untreated syrinx.

Conclusion: This small series does not lend support to the literature and anecdotal evidence for significantly increased surgical risk in deformity correction without treatment for syrinx first. However, this may reflect the fact that all syrinxes likely to compromise the surgical procedure were assessed as such and treated first. In the cohort of patients whose syrinxes were treated conservatively, a significant proportion did not require subsequent deformity surgery. Identifying a syrinx by, the mandatory, MR imaging of a patient with a deformity before considering surgical correction, appears to identify a significant proportion of syrinxes which neither significantly accelerate the progression deformity, or which do not lead to poor outcome after deformity surgery.

Introduction: Given the timing and nature of adolescent-onset idiopathic scoliosis (AIS), this progressively deforming condition is highly likely to have a significant psychosocial impact. Body image dissatisfaction is a frequent finding in AIS patients, which is of concern, as there is a well-documented causative link between body image disturbance and the formation of disordered eating behaviour, reflected in the theoretical models for this area of psychopathology.

However, although AIS patients have frequently been observed to exhibit disturbed body image, there has been no previous attempt to assess indications of disordered eating behaviour. Given the prevalence of AIS in adolescent females and the possible medical consequences of disordered eating, this study aimed to investigate whether AIS patients have an increased likelihood of low body weight.

Methods and Results: Patients were recruited over a four month period from the regional scoliosis out-patient clinic at St James’ University Hospital; 44 female scoliosis patients participated, with a mean age of 16 (range 13 to 19). All those meeting the inclusion criteria (diagnosed with AIS, not diagnosed with any other serious medical condition), and attending clinic over the data collection period were asked to participate.

Weight, height, and BMI (weight (kg)/height(m)2) measurements taken from AIS participants were compared to age and gender-adjusted normative data. No uncoiling correction was made for the scoliosis in terms of body height. The International Classification of Diseases (ICD-10) body mass criterion for eating pathology was used to determine how many AIS participants were within the range considered eating disordered.

Independent-sample t-tests revealed that, when compared to the normative data, the AIS group did not differ significantly in terms of height (p=0.646). However, they were significantly lighter (p< 0.001), and had significantly lower BMI scores (p< 0.001); 25% of the sample had a BMI score within the range considered anorectic. Of these low-BMI patients, the mean index score was 15.6 (range 12.9–17.5). The mean weight was 40.25 kg (6st 4lbs), with a range from 31.5 to 49 kg (4st 13lbs – 7st 11lbs). The body mass data for this low-BMI group, both in terms of range and severity, is not within ‘normal’ body shape variation, and would not be expected in healthy adolescent females.

Conclusion: The relationship between a diagnosis of AIS and low body weight may indicate disordered eating behaviour and is thus a cause for considerable concern. This is of particular relevance in the light of the well-established relationship between eating psychopathology and osteoporosis, which may result if disordered eating produces a reduced peak bone mass. Organic health consequences may need to be added to a matter previously considered to be one of cosmetic deformation.

We investigate the hypothesis that normal spinal shape is genetically determined raising the possibility that individuals with scoliosis may inherit an ‘at risk’ spinal shape leading to the clustering of scoliosis within families.

A large scale study of spinal topography (Quantec system) in straight-backed sibling pairs of schoolchildren was undertaken. All children had no family or past history of spinal pathology and passed a modified Adams forward bend test. 223 sibling pairs were scanned including 28 heterozygote and 11 homozygote pairs. Control groups were constructed by breaking the sibling pair and replacing the removed sibling with an age, sex matched, unrelated counterpart. A sagittal spine line was extracted and analysed using principal component analysis to produce four scores accounting for 97.5% of the cumulative variation in shape. The scores were analysed by intraclass correlation coefficients (ICC).

The results for the second score were:-

All sibling groups showed greater correlation of sagittal profile for the second principal component than unrelated controls. Significant correlations in shape were seen for both twin groups where no correlation was seen with controls. A significant correlation was observed in same sex pairings. This work suggests that some elements of spinal profile may be familial but also shows correlation with sex. Both of these observations may be important in the aetiology of idiopathic scoliosis.