We have treated 101 patients with scoliosis secondary to muscular dystrophy over a 13-year period; 64 had Duchenne’s muscular dystrophy, 33 spinal muscular atrophy and four congenital muscular dystrophy. The patients underwent a modified Luque (87) or Harrington-Luque instrumentation (14) combined with a limited Moe fusion in all except 27 cases. A mean of 13 levels was instrumented. The mean preoperative sitting Cobb angle was 84° (10 to 150) and the mean postoperative angle 40° (52% correction). Most patients (96%) were able to discard their braces and there was a high level of patient satisfaction (89.6%). Less correction was seen for severe curves, and there was a greater recurrence of postoperative pelvic tilt in those patients not instrumented to the sacrum. Although the incidence of minor or temporary complications was high, these occurred chiefly in the early high-risk patients with very severe curves and considerable pre-existing immobility.
We treated 183 patients with fractures of the odontoid process (109 type II, 74 type III) non-operatively. Union was achieved in 59 (54%) with type-II fractures. All type-III fractures united, but in 16 patients union was delayed. There was no correlation between union and the clinical or radiological outcome of the fractures. Selective vertebral angiography, carried out in 18 patients ten with acute fractures and eight with nonunion, showed that the blood supply to the odontoid process was not disrupted. Studies on ten adult axis vertebrae at post-mortem showed that the difference in the surface area between type-II and type-III fractures was statistically significant. Our findings show that an age of more than 40 years, anterior displacement of more than 4 mm, posterior displacement and late presentation contribute towards nonunion of type-II fractures.
We describe a patient with traumatic right-sided invagination of two consecutive laminae into the spinal canal. The injury resembled a greenstick fracture and resulted in an acute Brown-Séquard syndrome. There was also an undisplaced hangman’s fracture of the axis vertebra. These injuries were caused by an acute hyperextension and axial compression of the cervical spine. Open reduction and internal fixation of the laminar fractures without fusion was followed by full neurological recovery within six weeks.
Coccygectomy is a controversial operation. Some authors have reported good results, but others advise against the procedure. The criteria for selection are ill-defined. We describe a study to validate an objective criterion for patient selection, namely radiological instability of the coccyx as judged by intermittent subluxation or hypermobility seen on lateral dynamic radiographs when sitting. We enrolled prospectively 37 patients with chronic pain because of coccygeal instability unrelieved by conservative treatment who were not involved in litigation. The operation was performed by the same surgeon. Patients were followed up for a minimum of two years after coccygectomy, with independent assessment at two years. There were 23 excellent, 11 good and three poor results. The mean time to definitive improvement was four to eight months. Coccygectomy gave good results in this group of patients.
There is ambiguity concerning the nomenclature and classification of fractures of the ring of the second cervical vertebra (C2). Disruption of the pars interarticularis which defines true traumatic spondylolisthesis of C2, is often wrongly called a pedicle fracture. Our aim in this study was to assess the influence of asymmetry on the anatomical and functional outcome and to evaluate the criteria of instability established by Roy-Camille et al. We studied the plain radiographs and CT scans of 24 patients: 13 were judged to be asymmetrical, ten were considered unstable and 14 stable. Treatment was with a Minerva jacket in 15 fractures and by operation in nine. Surgery was undertaken in patients with severe C2 to C3 sprains. One patient with an unstable lesion refused operation and was treated conservatively with a poor radiological result. Our study showed that asymmetry of the fracture did not affect the outcomes of treatment and should not therefore influence decisions in treatment. The criteria of Roy-Camille seem to be reliable and useful. We prefer the posterior approach to the cervical spine, which allows both stabilisation of the fracture and correction of a local kyphosis.
There have been no previous reports of a spinal subdural haematoma occurring as a complication of spinal surgery. We highlight the pitfalls in the diagnosis and management of a subacute subdural haematoma resulting from a dural tear which occurred as a surgical complication of microdiscectomy.
Injury to the spinal cord without radiological abnormality often occurs in the skeletally immature cervical and thoracic spine. We describe four adult patients with this diagnosis involving the cervical spine with resultant quadriparesis. The relevant literature is reviewed. The implications for initial management of the injury, the role of MRI and the need for a high index of suspicion are highlighted.
We studied 32 patients with central cord syndrome who were managed conservatively. Six were under 50 years of age (group 1), 16 between 50 and 70 years (group 2) and ten over 70 years (group 3). At the time of discharge all patients in group 1 could walk independently and had good bladder control compared with 11 (69%) and 14 (88%) in group 2 and four (40%) and two (20%) in group 3, respectively. At follow-up after a mean of 8.6 years (4 to 15), ten patients had died leaving 22 in the study. All those in group 1 were alive, could walk independently and had bladder control. In group 2, 13 were alive of whom ten (77%) could walk independently and nine (69%) had bladder control. In group 3 only three were alive of whom only one was independent and none had bladder control. Function at discharge as measured by the ASIA motor scoring system was usually maintained or improved at follow-up, but patients over 70 years of age at injury did poorly.
We studied 23 patients with spondylolysis of the fifth lumbar vertebra (L5) and 20 with spondylolytic spondylolisthesis at this level. All were more than 40 years of age. The transverse processes at L5 were significantly wider in the former group than in the latter. We also dissected 56 cadavers to study the morphological relationship between the transverse process of L5 and the iliolumbar ligament, and found that the wider transverse process is associated with increased width of the posterior band of the iliolumbar ligament. If a patient with pars defects has wide transverse processes at L5, the lumbosacral junction may be stabilised by wide posterior bands of the iliolumbar ligament and the fifth lumbar vertebra by the ligament, preventing anterior displacement.
We recorded compound muscle action potentials (CMAPs) from the diaphragm in 15 normal volunteers, nine patients with lesions of the lower cervical cord (C5 to C8), one completely quadriplegic patient (C6) and seven patients with lesions at a higher cervical level (C1 to C4). Transcranial magnetic stimulation and electrical stimulation of the phrenic nerve were carried out. When the centre of the coil was placed on the interauricular line at a point 3 cm lateral to the vertex on the scalp, the CMAPs from the diaphragm had the largest amplitude and the shortest latency. There was no difference in the mean latency of the CMAPs recorded by transcranial magnetic stimulation in the normal volunteers and in the patients with lesions of the lower cervical cord. In the quadriplegic patient, the latency of the CMAPs was not delayed, but was prolonged in the patients with lesions at a higher level. Those evoked by electrical stimulation of the phrenic nerve were not prolonged in the patients with higher lesions. Our findings suggest that the prolongation of the latency by transcranial magnetic stimulation reflects dysfunction of the higher cervical cord. The combination of transcranial magnetic stimulation and electrical stimulation of the phrenic nerve can detect the precise level of the lesion in the motor tract to the diaphragm.
A total of 254 cases of synovial cysts of the spine have been reported in the English literature, but only eight have been associated with haemorrhagie. We describe a 55-year-old man with acute radiculopathy resulting from haemorrhage involving a synovial cyst at a lumbar facet joint. Traumatic factors could have caused bleeding around or into the synovial cyst. Treatment by resection of the cyst and evacuation of the haematoma led to complete neurological recovery.
We treated 31 patients aged 65 years or more with cervical spondylotic myelopathy by microsurgical decompression and fusion at a single most appropriate level, in spite of MRI evidence of compression at several levels. Spinal cord potentials evoked at operation localised the level responsible for the principal lesion at C3-4 in 18 patients, C4-5 in 11 and at C5-6 in two. Despite the frequent coexistence of other age-related conditions, impairing ability to walk, the average Nurick grade improved from 3.5 before operation to 2.2 at a mean follow-up of 48 months. There was also good recovery of finger dexterity and sensitivity. Operation at a single optimal level, as opposed to several, has the advantage of minimising complications, of particular importance in this age group.
An 18-year-old man who presented with weakness in his lower limbs, had an upper motor neurone lesion at the D12-L1 level. At laminectomy two stone-like objects were found which proved to be bundles of tiny pieces of wood. They are thought to have entered the cord through an abdominal penetrating injury sustained six years previously.
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.
We studied MR images of the spine in a consecutive series of 100 patients with acute compression of the spinal cord due to metastases. All patients had documented neurological deficit and histologically proven carcinoma. MRI was used to localise bony metastatic involvement and soft-tissue impingement of the cord. A systematic method of documenting metastatic involvement is described. A total of 43 patients had compression at multiple levels; 160 vertebral levels were studied. In 120 vertebrae (75%), anterior, lateral and posterior bony elements were involved. Soft-tissue impingement of the spinal cord often involved more than one quadrant of its circumference. In 69 vertebrae (43%) there was concomitant anterior and posterior compression. Isolated involvement of a vertebral body was observed in only six vertebrae (3.8%). We have shown that in most cases of acute compression of the spinal cord due to metastases there is coexisting involvement of both anterior and posterior structures.
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.
Degenerative spondylolisthesis is four times more common in women than in men. Although this gender difference has long been recognised there has been no explanation for it. We have examined the radiographs and CT scans of 118 patients over the age of 55 years and of a control group under the age of 46 years. Our findings confirmed the presence of more sagittally-orientated facet joints in patients with degenerative spondylolisthesis but did not show that the gender difference can be explained by the morphology of the facet joint. Furthermore, we conclude that the increased angle of the facet joint is the result of arthritic remodelling and not the primary cause of degenerative spondylolisthesis. It is more likely to be due to loss of soft-tissue resilience with subsequent failure of the facet joints which are acting as the last restraints to subluxation.
We report two cases of vertebral osteochondroma. In one patient a solitary cervical lesion presented as entrapment neuropathy of the ulnar nerve and in the other as a thoracic tumour associated with hereditary multiple exostoses producing paraplegia. We highlight the importance of an adequate preoperative evaluation in such patients.
We describe a rare herniation of the disc at the C2/C3 level in a 73-year-old woman. It caused hemicompression of the spinal cord and led to the Brown-Sequard syndrome. The condition was diagnosed clinically and by MRI six months after onset. Discectomy and fusion gave complete neurological resolution.
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 have reviewed 81 patients with fractures of the odontoid process treated between May 1983 and July 1997, by anterior screw fixation. There were 29 patients with Anderson and D’Alonzo type-II fractures and 52 with type III. Roy-Camille’s classification identified the direction and instability of the fracture. Operative fixation was carried out on 48 men and 33 women with a mean age of 57 years. Associated injuries of the cervical spine were present in 15 patients, neurological signs in 13, and 18 had an Injury Severity Score of more than 15. Nine patients died and 11 were lost to follow-up. Of 61 patients, 56 (92%) achieved bony union at an average of 14.1 weeks. Two patients required a secondary posterior fusion after failure of the index operation. A full range of movement was restored in 43 patients; only six had a limitation of movement greater than 25%. We conclude that anterior screw fixation is effective and practicable in the treatment of fractures of the dens.
We have treated seven patients with cryptococcal spondylitis. Five presented with a neurological deficit and one was HIV-positive. Amphotericin-B and 5-flucytosine were used in five patients and ketoconazole was given orally in the remaining two. Three patients made a complete neurological recovery. Since these lesions mimic spinal tuberculosis, which is commonly seen in our environment, we draw attention to the importance of obtaining a tissue diagnosis.
We reviewed the radiographs of 325 unselected patients with defects in the pars interarticularis of L5 to study whether the incidence of vertebral slip in spondylolysis of L5 remained unchanged after the age of 20 years. MRI was also carried out on 111 of the patients to investigate the relationship between the shape of the transverse process of L5 and the degeneration of the discs adjacent to this level. The incidence of spondylolisthesis increased with age from 17% in the second decade to 51% in the sixth. The transverse process was significantly more slender in patients with less degeneration at L4/5 and advanced degeneration at L5/S1 than in patients with advanced degeneration at L4/5 and less degeneration at L5/S1. Vertebral slip secondary to an isthmic defect of L5 after the age of 20 years was confirmed and the adjacent disc degeneration was significantly related to the vertical thickness of the transverse process of L5.
We have developed criteria to determine the appropriate indications for lumbar laminectomy, using the standard procedure developed at the RAND corporation and the University of California at Los Angeles (RAND-UCLA). A panel of five surgeons and four physicians individually assessed 1000 hypothetical cases of sciatica, back pain only, symptoms of spinal stenosis, spondylolisthesis, miscellaneous indications or the need for repeat laminectomy. For the first round each member of the panel used a scale ranging from 1 (extremely inappropriate) to 9 (extremely appropriate). After discussion and condensation of the results into three categories laminectomy was considered appropriate in 11% of the 1000 theoretical scenarios, equivocal in 26% and inappropriate in 63%. There was some variation between the six categories of malalignment, but full agreement in 64% of the hypothetical cases. We applied these criteria retrospectively to the records of 196 patients who had had surgical treatment for herniated discs in one Swiss University hospital. We found that 48% of the operations were for appropriate indications, 29% for equivocal reasons and that 23% were inappropriate. The RAND-UCLA method is a feasible, useful and coherent approach to the study of the indications for laminectomy and related procedures, providing a number of important insights. Our conclusions now require validation by carefully designed prospective clinical trials, such as those which are used for new medical techniques.
The ratio of the sagittal diameter of the cervical canal to the corresponding diameter of the vertebral body has been described as a reliable means for assessing stenosis of the canal and detecting those at risk of cervical neuropraxia. The use of ratio techniques has the advantage of avoiding variation in magnification when direct measurements are made from plain radiographs. We examined the reliability of this method using plain lateral radiographs of unknown magnification and CT scans. We also assessed other possible ratios of anatomical measurements as a guide to the diameter of the canal. Our findings showed a poor correlation between the true diameter of the canal and the ratio of its sagittal diameter to that of the vertebral body. No other more reliable ratio was identified. The variability in anatomical morphology means that the use of ratios from anatomical measurements within the cervical spine is not reliable in determining the true diameter of the cervical canal.
Fresh-frozen allografts from the humerus were used to help to stabilise the spine after anterior decompression for tuberculosis in 47 children with a mean age of 4.2 years (2 to 9). The average angle of the gibbus, before operation, was 53°; at follow-up, two years later, it was 15°. Rejection of the graft or deep sepsis was not seen. Cross trabeculation between the allograft and the vertebral body was observed at six months, with remodelling occurring at approximately 30 months.
We have measured the dynamic movement of the lumbar spine in 57 patients with degenerative lumbar disc disease. Each completed a questionnaire which recorded pain and subjective signs and symptoms. From plain lateral radiographs, the subjects were graded using the criteria of Kellgren and Lawrence and those of Lane et al, which are both based on the severity of degenerative changes. Measurements of the height of the disc space and the vertebral height were obtained and expressed as a ratio. We found no relationship between the characteristics of spinal movement and the overall grading of degenerative disc disease with either system. Both were influenced (p <
0.01) by age, walking distance, severity of symptoms, drug intake and frequency of pain. The present systems for grading degenerative disc disease from plain lateral radiographs have limited application.
We treated 12 patients with multilevel stenosis of the cervical canal after spondylosis or ossification of the posterior longitudinal ligament by an expansive open-door laminoplasty, stabilised by using an anchor system. The preoperative sagittal diameter of the canal was 9.8 mm(±2.2) which was increased to 16.1 mm (±2.9) after surgery. The mean expansion ratio of the canal was 64% (42 to 100). The anchoring systems did not fail during the follow-up period (mean 29.5 months), and the decompression was maintained. The use of anchor systems to stabilise the posterior elements after laminoplasty is a simple and effective technique for maintaining the increased sagittal diameter of the canal.
We have studied the intervertebral discs adjacent to fractured vertebral bodies using MRI in 63 patients at a minimum of 18 months after injury. There were 75 thoracolumbar fractures of which 26 were treated conservatively and 37 by posterior reduction and fusion with an AO internal fixator. We identified six different types of disc using criteria based on the morphology and the intensity of the MRI signal. The inter- and intraobserver variability of this system was good. Most of the discs showed predominantly morphological changes with no variation in signal intensity. Some disc types were associated with progressive kyphosis in patients treated conservatively. In those managed by operation, recurrent kyphosis appeared to result from creeping of the disc in the central depression of the bony endplate rather than from disc degeneration. Changes in the disc space after posterior fixation should not be seen as a form of chronic instability but as a redistribution of the disc tissue in the changed morphology of the space after fractures of the endplate.
We analysed prospectively 26 patients who had revision operations for ipsilateral recurrent radicular pain after a period of pain relief of more than six months following primary discectomy. They were assessed before the initial operation, between the two procedures and at a minimum of two years after reoperation. MRI was performed before primary discectomy and reoperation. Fifty consecutive patients who had a disc excision during the study period but did not have recurrent radicular pain, were analysed as a control group. Of the study group 42% related the onset of recurrent radicular pain to an isolated injury or a precipitating event, but none of the control group did so (p <
0.001). T2-weighted MRI performed before primary discectomy showed that patients in the study group had significantly more severe disc degeneration compared with the control group (p = 0.02). Intraoperative findings revealed recurrent disc herniation in 24 patients and bulging of the disc in two, one of whom also had lateral stenosis. Epidural scarring was found to be abundant, intraoperatively and on MRI, in eight and in nine patients, respectively. At the last follow-up, the clinical outcome was satisfactory in 85% of patients in the study group and in 88% of the control group (p >
0.05). Work or daily activities had been resumed at the same level as before the onset of symptoms by 81% of the patients in the study group and 84% of the control group. No correlation was found between the amount of epidural fibrosis, as seen intraoperatively and on MRI, and the result of surgery. The recurrence of radicular pain caused no significant changes in the psychological profile compared with the assessment before the primary discectomy.
Postoperative radiculopathy is a complication of posterior cervical decompression associated with tethering of the nerve root. We reviewed retrospectively 287 consecutive patients with cervical compression myelopathy who had been treated by multilevel cervical laminectomy and identified 37 (12.9%) with postoperative radiculopathy. There were 27 men and ten women with a mean age of 56 years at the time of operation. The diagnosis was either cervical spondylosis (25 patients) or ossification of the posterior longitudinal ligament (12 patients). Radiculopathy was observed from four hours to six days after surgery. The most frequent pattern of paralysis was involvement of the C5 and C6 roots of the motor-dominant type. The mean time for recovery was 5.4 months (two weeks to three years). The results at follow-up showed that the rate of motor recovery was negatively related to the duration of complete recovery of postoperative radiculopathy (γ = −0.832, p <
0.01) and that patients with spondylotic myelopathy had a significantly better rate of clinical recovery than those with ossification of the posterior longitudinal ligament (t = 2.960, p <
0.01). Postoperative radiculopathy may be prevented by carrying out an anterior decompression in conjunction with spinal fusion, which will achieve stabilisation and directly remove compression of the cord at multiple levels.
We have studied fracture-dislocation of the fifth lumbar vertebra in seven patients and reviewed 50 previously reported cases. Based on this information, we have classified the injury into five types: type 1, unilateral lumbosacral facet-dislocation with or without facet fracture; type 2, bilateral lumbosacral facet-dislocation with or without facet fracture; type 3, unilateral lumbosacral facet-dislocation and contralateral lumbosacral facet fracture; type 4, dislocation of the body of L5 with bilateral fracture of the pars interarticularis; and type 5, dislocation of the body of L5 with fracture of the body and/or pedicle, with or without injury of the lamina and/or facet. Conservative treatment of fracture-dislocation of L5 is generally not effective because the lesion is fundamentally unstable. Planning of the operation should be made on the basis of the various types of injury.
We injected methylene blue dye into 32 of the facet joints immediately above the defects in 17 consecutive patients with bilateral spondylolysis (34 defects). In 30 of these the dye flowed into a central cavity in the defect of the pars interarticularis and in 20 it passed into the facet joint below the defect. We found macroscopic cavities in 32 of the defects which communicated with the adjacent facet joints and had fibrous capsules. Histological examination showed focal areas of synovial lining consistent with a synovial pseudarthrosis. In most patients requiring surgery for spondylolysis, the defect is a synovial pseudarthrosis which communicates with the facet joint above it, and less often with the facet joint below it. We suggest that stress fractures of the pars may fail to heal because of the presence of synovial fluid from a nearby facet joint.
We made a prospective study of 43 consecutive patients treated for intraforaminal (34) or extraforaminal (9) herniations of a lumbar disc by excision through an interlaminar approach, using an operating microscope. The intraforaminal herniations were contained or extruded in 52% and sequestrated in 47%; for extraforaminal herniation the proportions were 66% and 33%, respectively. There was additional posterolateral protrusion or spinal stenosis at the level of the lateral herniation in seven and four cases, respectively. The patients were reviewed at three months and two years after surgery. Radiographs showed three grades of facetectomy: grade I, removal of 50% or less, grade II, excision of 51% to 75%, and grade III, subtotal or total facetectomy. For intraforaminal herniations the results were excellent or good in 88% of patients when reviewed at three months and in 91% at two years. For extraforaminal herniations, there was an excellent or good outcome in 89% of patients in the short term and in all in the long term. The facetectomy had been grade I in 14 and grade II in 25; it had been grade III in four, but only one had had total facetectomy. No patient had developed vertebral hypermobility as a result of the operation. An intralaminar approach using an operating microscope can provide adequate access to a lateral protrusion. It has the advantage of allowing the treatment of posterolateral protrusion or posterior annular bulge and of spinal stenosis at the same level.
We investigated 21 pairs of twins for zygosity and idiopathic scoliosis. DNA fingerprinting confirmed that 13 pairs were monozygotic and eight were dizygotic. There was concordance for idiopathic scoliosis in 92.3% of monozygotic and 62.5% of dizygotic twins. Of the 12 pairs of monozygotic twins concordant for idiopathic scoliosis, six showed discordant curve patterns but eight had differences in Cobb angle of less than 10°. Seven of the ten pairs of monozygotic twins had similar back shapes. Our findings suggest that there is a genetic factor in the aetiology of idiopathic scoliosis; they also indicate that there is a genetic factor in both the severity of the curve and the general shape of the back.
Lateral oblique radiographs are considered important for the identification of spondylolytic lesions, but these projections will give a clear view only when the radiological beam is in the plane of the defect. We studied the variation in orientation of spondylolytic lesions on CT scans of 34 patients with 69 defects. There was a wide variation of angle: only 32% of defects were orientated within 15° of the 45° lateral oblique plane. Lateral oblique radiographs should not be considered as the definitive investigation for spondylolysis. We suggest that CT scans with reverse gantry angle are now more appropriate than oblique radiography for the assessment of spondylolysis. Variation in the angle of the defect may also need consideration when direct repair is being planned.
We studied degenerative changes in the cervical intervertebral discs of 497 asymptomatic subjects by MRI and evaluated disc degeneration by loss of signal intensity, posterior and anterior disc protrusion, narrowing of the disc space and foraminal stenosis. In each subject, five disc levels from C2–C3 to C6–C7 were evaluated. The frequency of all degenerative findings increased linearly with age. Disc degeneration was the most common observation, being present in 17% of discs of men and 12% of those of women in their twenties, and 86% and 89% of discs of both men and women over 60 years of age. We found significant differences in frequency between genders for posterior disc protrusion and foraminal stenosis. The former, with demonstrable compression of the spinal cord, was observed in 7.6% of subjects, mostly over 50 years of age. Our results should be taken into account when interpreting the MRI findings in patients with symptomatic disorders of the cervical spine.
We performed CT myelography in 38 patients with cervical myelopathy before and after laminoplasty to enlarge the canal. The sagittal and transverse diameters, the cross-sectional area, and the central point of the spinal cord were measured. After cervical laminoplasty, the mean sagittal diameter of the spinal cord at C5 increased by 0.8 mm, but the mean transverse diameter decreased by 0.9 mm. The mean cross-sectional area of the cord increased by 7.4% and that of the dural sac and its contents by 33.8% at C5. The centre of the spinal cord moved a mean 2.8 mm posteriorly at this level. Enlargement of the spinal canal is sufficient to decompress the spinal cord, but posterior movement may be the limiting factor in determining the decompressive effect of laminoplasty.
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.
We have evaluated the use of a synthetic porous ceramic (Triosite) as a substitute for bone graft in posterior spinal fusion for idiopathic scoliosis. In a prospective, randomised study 341 patients at five hospitals in the UK and France were randomly allocated either to autograft from the iliac crest or rib segments (171) or to receive Triosite blocks (170). All patients were assessed after operation and at 3, 6, 12 and 18 months. The two groups were similar with regard to all demographic and baseline variables, but the 184 treated in France (54%) had Cotrel-Dubouset instrumentation and the 157 treated in the UK usually had Harrington-Luque implants. In the Triosite group the average Cobb angle of the upper curve was 56°, corrected to 24° (57%). At 18 months, the average was 26° (3% loss). In the autograft group the average preoperative upper curve of 53° was corrected to 21° (60%). At 18 months the mean curve was 25° (8% loss). Pain levels after operation were similar in the two groups, being mild in most cases. In the Triosite group only three patients had problems of wound healing, but in the autograft group, 14 patients had delayed healing, infection or haematoma in the spinal wound. In addition, 15 autograft patients had pain at the donor site at three months. Seven had infections, two had haematoma and four had delayed healing. The haematological and serum biochemistry results showed no abnormal trends and no significant differences between the groups. There were no adverse events related to the graft material and no evidence of allergenicity. Our results suggest that Triosite synthetic porous ceramic is a safe and effective substitute for autograft in these patients. Histological findings on biopsy indicate that Triosite provides a favourable scaffolding for the formation of new bone and is gradually incorporated into the fusion mass.
A four-year-old boy presented with a solitary bone cyst in the odontoid process and body of the axis. Plain radiographs showed a radiolucent lesion with extreme thinning of the cortex and MRI demonstrated a high signal intensity in the interlesional matrix. The cystic component extended into the body of the axis through a defect in the epiphyseal plate. At operation, the cavity of the cyst was found to contain serosanguineous fluid, and histological examination showed that it was lined by a thin layer of connective tissue. The cyst may have originated from a defect in the epiphyseal plate.
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.
Of a total of 330 patients requiring operation on a lumbar disc, 20 (6.1%) with lateral disc prolapse had a new muscle-splitting, intertransverse approach which requires minimal resection of bone. There were 16 men and 4 women with a mean age of 52 years. All had intense radicular pain, 15 had femoral radiculopathy and 19 a neurological deficit. Far lateral herniation of the disc had been confirmed by MRI. At operation, excellent access was obtained to the spinal nerve, dorsal root ganglion and the disc prolapse. The posterior primary ramus was useful in locating the spinal nerve and dorsal root ganglion during dissection of the intertransverse space. At review from six months to four years, 12 patients had excellent results with no residual pain and six had good results with mild discomfort and no functional impairment. Two had poor results. There had been neurological improvement in 17 of the 20 patients. We report a cadaver study of the anatomy of the posterior primary ramus. It is readily identifiable through this approach and can be traced down to the spinal nerve in the intertransverse space. We recommend the use of a muscle-splitting intertransverse approach to far lateral herniation of the disc, using the posterior primary ramus as the key to safe dissection.
We have reviewed 59 patients with injury to the spinal cord to assess the predictive value of the sparing of sensation to pin prick in determining motor recovery in segments which initially had MRC grade-0 power. There were 35 tetraplegics (18 complete, 17 incomplete) and 24 paraplegics (19 complete, 5 incomplete), and the mean follow-up was 29.6 months. A total of 114 motor segments initially had grade-0 power but sparing of sensation to pin prick in the corresponding dermatome. Of these, 97 (85%) had return of functional power (≥ grade 3) at follow-up. There were 479 motor segments with grade-0 power but no sparing of sensation to pin prick and of these only six (1.3%) had return of functional power. Both of the above associations were statistically significant (chi-squared test, p <
0.0001). After injury to the spinal cord, the preservation of sensation to pin prick in a motor segment with grade-0 power indicated an 85% chance of motor recovery to at least grade 3.
We report an unusual presentation of a solitary plasma-cell myeloma of the spine in an adolescent patient. Our case indicates the need to consider plasma-cell myeloma as a differential diagnosis even in younger patients.
We describe the successful relief of compression of the spinal cord due to a vertebral haemangioma by transcatheter embolisation using cyanoacrylate compounds before operation, and provide a brief review of the literature.
Between 1986 and 1995, we treated with foraminal injection of local anaesthetic and steroids 30 patients with severe lumbar radiculopathy secondary to foraminal and extraforaminal disc herniation which had not resolved with rest and non-steroidal anti-inflammatory agents. They were assessed prospectively using standardised forms as well as the Low Back Outcome Score, and were reviewed at an average of 3.4 years (1 to 10) after injection by an independent observer (BKW). Relief of symptoms was obtained in 27 immediately after injection. Three subsequently relapsed, requiring operation, and two were lost to long-term follow-up. Thus 22 of the 28 patients available for long-term follow-up had considerable and sustained relief from their symptoms. Before the onset of symptoms 17 were in employment and, after injection, 13 resumed work, all but two in the same job. The average score before injection was 25 out of a possible 75 points. At follow-up, the overall average score was 54, and in those who had obtained relief of symptoms it had improved to a mean of 61. Based on these findings we recommend foraminal injection of local anaesthetic and steroids as the primary treatment for patients with severe radiculopathy secondary to foraminal or extraforaminal herniation of a lumbar disc.
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.
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.
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 describe an unusual injury to the upper cervical spine sustained during ejection from an aircraft. MRI provided an accurate and direct diagnosis of the severe ligamentous injuries.
Fifteen patients with ankylosing spondylitis who had developed a severe flexion deformity of the cervical spine which restricted their field of vision to their feet, were treated by an extension osteotomy at the C7/T1 level. The operation was performed under general anaesthesia with the patient in the prone position and wearing a halo-jacket. Three had internal fixation using a Luque rectangle and wiring. Their mean age was 48 years. Before operation the mean cervical kyphosis was 23°; this was corrected to a mean of 31° of lordosis, a mean correction of 54°. All the patients were able to see straight ahead. One patient with normal neurology soon after operation became quadraparetic after one week; two others had unilateral palsy of the C8 root, which improved. There was subluxation at the site of osteotomy in four patients, and two of them developed a pseudarthrosis which required an anterior fusion.
We reviewed retrospectively the role of monitoring of somatosensory spinal evoked potentials (SSEP) in 99 patients with neuromuscular scoliosis who had had operative correction with Luque-Galveston rods and sublaminar wiring. Our findings showed that SSEP monitoring was useful and that a 50% decrease in the amplitude of the trace optimised both sensitivity and specificity. The detection of true-positive results was higher than in cases of idiopathic scoliosis, but the method was less sensitive and specific and there were more false-negative results. In contrast with the findings in idiopathic scoliosis, recovery of the trace was associated with a 50% to 60% risk of neurological impairment. Only one permanent injury occurred during the use of this technique, and any temporary impairment resolved within two months.
A vascularised fibular strut graft was used for anterior spinal fusion in 16 patients with spinal kyphosis. The procedure was abandoned in three because of difficulty in establishing a vascular anastomosis and in one because the grafted fibula dislodged two days after operation. One patient died after five days. Of the 11 remaining patients, there were seven males and four females. Their ages at the time of operation averaged 30.9 years (12 to 71). The number of vertebrae fused averaged 6.7 (5 to 9) and the length of fibula grafted averaged 10.9 cm (6.5 to 18). Average follow-up was 54 months (27 to 84). Bone union occurred at both ends of the grafted fibula in all 11 patients, with an average time to union of 5.5 months (3 to 8). We did not see a fracture of the grafted fibula. Two patients had postoperative complications; the graft dislodged in one and laryngeal oedema occurred two days after operation in the other. A vascularised fibular strut graft provides a biomechanically stable and long-standing support in spinal fusion because the weak phase of creeping substitution does not take place in the graft.
The Short Form-36 (SF-36) health questionnaire has been put forward as a general measure of outcome in health care and has been evaluated in several recent studies in the UK. We report its use in three groups of patients after spinal operations and have compared it with the Oswestry and Low Back Pain disability scales. There was a significant correlation between all variables of the SF-36 and the low-back scores. The mental-health items had the weakest correlation. Our study shows that the SF-36 questionnaire is valid and has internal consistency when applied to these patients.
Degenerative spondylolisthesis is most common at the L4/L5 level and in women. There are several possible reasons for its predilection at this site, but there is no satisfactory explanation for the predominance in women. We considered that pregnancy was a possible influence. We reviewed the records and radiographs of 949 women and 120 men aged 50 years and over who had attended a spinal surgeon for low back pain over a five-year period. We found that women who had borne children had a significantly higher incidence of degenerative spondylolisthesis than nulliparous women (28%
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.
We analysed the cases of lumbar kyphosis in 151 (21%) of a series of 719 patients with myelomeningocele. Three different types were distinguished: paralytic, sharp-angled and congenital. In a cross-sectional and partly longitudinal study the size and magnitude of the kyphosis, the apex of the curve and the level of paralysis of each group were recorded and statistically analysed. Paralytic kyphosis (less than 90° at birth) occurred in 44.4% and increased linearly during further development. Sharp-angled kyphosis (90° or more at birth) was present in 38.4% and also showed a linear progression. In both types, progression seemed to depend also on the level of paralysis. Congenital kyphosis occurred in 13.9% and we could find no significant factor which correlated with progression.
Forty patients with a whiplash injury who had been reviewed previously 2 and 10 years after injury were assessed again after a mean of 15.5 years by physical examination, pain and psychometric testing. Twenty-eight (70%) continued to complain of symptoms referable to the original accident. Neck pain was the commonest, but low-back pain was present in half. Women and older patients had a worse outcome. Radiating pain was more common in those with severe symptoms. Evidence of psychological disturbance was seen in 52% of patients with symptoms. Between 10 and 15 years after the accident 18% of the patients had improved whereas 28% had deteriorated.
We performed intercostal nerve transfer in 19 patients to relieve pain from preganglionic injury to the brachial plexus. The procedure was successful in 16 patients at a mean of 28.6 months (12 to 68) after the injury.
We have assessed the efficacy of free nerve grafts in 90 cases of brachial plexus injury. Relatively good recovery of the elbow flexor and extensor muscles and of those of the shoulder girdle was found but recovery of the flexors and extensors of the forearm and of the intrinsic muscles of the hand was extremely poor. Poor results were found when spinal nerve roots seemed normal to the touch and appeared intact but had abnormal somatosensory evoked potentials or myelography. Recovery of the deltoid and infraspinatus muscles was better when injury had occurred to the circumflex and suprascapular nerves rather than to the plexus itself, perhaps because these nerves were explored in their entirety to determine the presence of multiple lesions. It is important to visualise the entire nerve thoroughly to assess the overall condition. Thorough exploration of the plexus and the use of intraoperative recording of somatosensory evoked potentials are essential.
We have reviewed the cervical spine radiographs of 180 patients with athetoid cerebral palsy and compared them with those of 417 control subjects. Disc degeneration occurred earlier and progressed more rapidly in the patients, with advanced disc degeneration in 51%, eight times the frequency in normal subjects. At the C3/4 and C4/5 levels, there was listhetic instability in 17% and 27% of the patients, respectively, again six and eight times more frequently than in the control subjects. Angular instability was seen, particularly at the C3/4, C4/5 and C5/6 levels. We found a significantly higher incidence of narrowing of the cervical canal in the patients, notably at the C4 and C5 levels, where the average was 14.4 mm in the patients and 16.4 mm in normal subjects. The combination of disc degeneration and listhetic instability with a narrow canal predisposes these patients to relatively rapid progression to a devastating neurological deficit.
The afferent pathways of discogenic low-back pain have not been fully investigated. We hypothesised that this pain was transmitted mainly by sympathetic afferent fibres in the L2 nerve root, and in 33 patients we used selective local anaesthesia of this nerve. Low-back pain disappeared or significantly decreased in all patients after the injection. Needle insertion provoked pain which radiated to the low back in 23 patients and the area of skin hypoalgesia produced included the area of pre-existing pain in all but one. None of the nine patients with related sciatica had relief of that component of their symptoms. Our findings show that the main afferent pathways of pain from the lower intervertebral discs are through the L2 spinal nerve root, presumably via sympathetic afferents from the sinuvertebral nerves. Discogenic low-back pain should be regarded as a visceral pain in respect of its neural pathways. Infiltration of the L2 nerve is a useful diagnostic test and also has some therapeutic value.
We report a series of 15 children, six male and nine female, of average age 20 months, seen at a paediatric orthopaedic clinic with torticollis. Orthopaedic examination revealed a normal range of neck movement in all cases but in seven there was palpable tightness in the absence of true shortening or contracture of the sternomastoid muscle. The patients were prospectively referred for ocular examination. In five of the 15 an ocular cause for the torticollis was detected with underaction of the superior oblique muscle in three, paresis of the lateral rectus muscle in one and nystagmus in one. Another two patients were found to have an abnormal ocular examination which was thought to be unrelated to their torticollis. Three of the patients with ocular torticollis required extra-ocular muscle surgery to abolish the head tilt and one of these had a tight sternomastoid muscle. Two of the non-ocular group had surgical release of the sternomastoid muscle; in the rest, the condition either resolved with physiotherapy or required no active treatment. We recommend that all patients with torticollis and no clear orthopaedic cause are referred for ocular assessment since it is not possible clinically to distinguish ocular from non-ocular causes.
