To determine factors such as age, sex and curve severity in patients with idiopathic scoliosis presenting for the first time to a spine deformity clinic.

A prospective study at a regional spine clinic.

Patients with idiopathic scoliosis presenting for the first time to the scoliosis clinic were entered into a database recording information such as age, symptoms, severity of scoliosis as measured by the Cobb angle (CA), spine rotation measured by Scoliometer, geographical region, person detecting the curve, neurological findings etc. The study period was from June 2008 to September 2009 inclusive.

Fifty consecutive patients with all required information in the database were included in the analysis. All eligible patients were not entered due to logistical reasons.

13 males and 37 females, average age 13.96 (range 1 to 23). 68% were unhappy with the shape of their back, 48% presented with significant pain and 32% had both. The mother first saw the scoliosis in 52%, the rest were seen by either the patient, friends or doctors.

36 were single curves with a mean CA of 34 degrees ranging from 10 to 80 degrees. 52% of patients presented with a curve of 40 degrees or more. 14 had double curves. None of the patients were found to have any abnormal neurological findings.

There are few epidemiological studies in the recent literature. This data was not previously available in our region and initial presentation with a severe curve is a worrying trend which triggered this study.

Several human conditions have a tendency to affect one side of the body over the other. Do lumbar disc prolapses have such a tendency? We sought to answer this question by an analysis of operated cases.

Primary lumbar microdiscectomy cases were identified using the coding system. 1286 cases were identified and in 764 the laterality was not recorded. Electronic records were then examined to establish, where possible, the side of the procedure from the clinic letter or discharge summary. 22 cases were eliminated due to miscoding (laminectomy, instrumentation, revision) and in 24 the side of the operation could not be established. In the remaining 1240 cases (96.4%) the laterality was determined.

Patients who underwent primary lumbar microdiscectomy in a single neurosurgical unit over a 5-year period (2002-2007).

Procedures were bilateral, left or right.

126 cases were bilateral. There were 1114 defined lateral cases. 618 (55.5%) were on the left compared to 496 (44.5%) on the right. The ratio of left to right is close to 5:4. The null hypothesis was that the number of left and right sided operations would be equal. The findings of this study were statistically highly significant (p value < 0.001, binomial test) and the null hypothesis could be rejected.

There is a small but definite preponderance of left sided over right sided cases at a ratio of 5:4. This finding may have implications regarding our understanding of both the epidemiology and biomechanics of lumbar disc prolapse.

To review our practice of requesting nerve root blocks, to see how effective our therapeutic blocks are and how many of our diagnostic blocks confirm clinical suspicion and help decision making.

Retrospective cohort analysis

120 fluoroscopically guided nerve root blocks were performed between 20/08/2008 and 29/12/2008. There were 100 patients who had pain diary data available, 42 males (mean age 52.02 range 20-76) 58 females (mean age 60.03, range 22-88).

We recorded: clinical diagnosis, reason for block, result of block on a 10 point visual analogue pain diary on days 0, 2, 14 and at review. A successful block was defined as an improvement of at least 2 points. For the diagnostic blocks we also recorded whether the block result influenced surgical decision making.

Block methods will be illustrated in diagram. Results will be displayed graphically and in text. 18 blocks were cervical (1 purely diagnostic, 6 therapeutic, and 10 mixed, 1 data unavailable). 71 blocks were lumbar (1 purely diagnostic, 28 purely therapeutic, and 37 mixed, 5 data unavailable). 28% of all blocks were successful immediately (2 unavailable data) and 22% at two weeks (1 unavailable data). By 3 months the success rate for therapeutic blocks was 26%. Of the blocks done for diagnostic reasons, 86% influenced a clinical decision at the next outpatient appointment.

Our results justify the continuance of this service. Increased care should be taken that patients' outcome data is collected.

To compare outcomes and costs of transforaminal endoscopic surgical discectomy (TES) with those of microdiscectomy (Micro)

48 patients with a primary lumbar disc prolapse were randomly allocated by computer to surgery.

Assessments were made of leg and back pain (VAS), Oswestry Disability index (ODI), and SF-36 as primary outcomes. Cost data was collated.

25 TES and 23 Micro patients are reported with similar age, sex, smoking status and affected disc levels (14 v.17 L5/S1). Three months following surgery leg pain scores had decreased by 55 and 65% in the two groups. Patient satisfaction ratings were equal. ODI had decreased 15 points in both groups by 1yr and this improvement was maintained to 2 years (final scores: 7±3 TES v.14±13 Micro - means ±SD; p<0.05). Similar changes were noted in SF36-P. Mean bed stay was lower in the TES group (16 v. 40 hours). Other post-operative costs were similar. There were no immediate complications. One revision was required at 12 months (TES) and one at 18 months (Micro). Two patients presented with a disc prolapse at a different level and side (both TES).

Results at up to two years follow-up are similar following the two interventions. Recovery was more rapid in those patients undergoing endoscopic surgery.

To assess the effectiveness of dynamic stabilisation as a treatment for discogenic pain compared to standard treatment of interbody fusion.

All patients were referred for a 2 year back-pain management programme. Patients with continued pain following conservative treatment underwent discography & MRI. Patients with painful degenerate discs on the above investigations were selected.

Patients underwent interbody fusion (PLIF/TLIF) or dynamic stabilisation.

Mean follow-up was 24 months with a minimum follow-up of 12 months.

All patients had pre-operative ODI and VAS scores. Patients were then sent further questionnaires at 6 month intervals.

The mean improvement in ODI following dynamic stabilisation was 20% (-20% → 56%), the mean improvement in the pain score was 2.4 (0→8).

The mean improvement in ODI following interbody fusion was 11% (-14%→48%), the mean improvement in the pain score was 2.6 (-4→9).

10 patients in the dynamic stabilisation group had a greater than 20% improvement in ODI, 7 patients in the interbody fusion group had similar results.

The above results demonstrate that dynamic stabilisation is at least as effective at treating discogenic pain as interbody fusion. The results however do question the validity of either interbody fusion (PLIF/TLIF) or dynamic stabilisation in the management of discogenic pain.

Peninsula Spinal Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Foundation NHS Trust, Exeter, UK.

A retrospective audit in 2000 of cases presenting with metastatic cord compression (MSCC) was conducted. In June 2009 we introduced the role of MSCC coordinator. We present the preliminary results from a 6 month comparative audit and discuss whether implementation of the NICE Guidelines have improved the care pathway.

Prospective cohort study with retrospective controlled group.

Adults with suspected MSCC

Length of time to MR imaging

% referred for surgical opinion

Length of time on bed rest.

% undergoing surgery

Retrospective audit 2000

38 cases confirmed MSCC.

11 did not have MRI and were treated on the basis of clinical symptoms.

Average time from admission to MRI 42 hours.

8 patients (21%) referred for surgical opinion.

None had surgery

38 had radiotherapy.

Spinal stability documented on 1 patient.

5.5 days average bed rest

Prospective audit 2009

54 patients referred to co-ordinator as suspected MSCC.

52 had MRI and 2 had CT.

Average time from referral to MRI 41 hours.

Average time for patients with neurological deficit 7.6 hours.

54 patients (100%) referred for surgical opinion.

12 patients had surgery (22%).

100% patients had spinal stability documented.

Average length of time on bed rest 2 days.

It is uncertain whether these results are attributed to the introduction of the NICE guidelines or improved awareness of condition. However we feel that NICE guidelines have improved the care pathway of patients with MSCC.

Statement of ethics and interests: Study was approved and registered with audit department.

Comparison of clinical, radiological & functional outcomes of corrective surgery for right thoracic AIS curves.

There is a paucity of data relating functional outcomes to the radiological and surface measurement results of either posterior or anterior surgery for right thoracic AIS.

Prospective, cohort study, mean follow up 35 months (range 9-115)

38 patients (6 males); 22 Lenke 2 posterior, 16 Lenke 1 anterior.

Primary= rib hump, radiological (frontal Cobb correction, apical vertebral translation AVT, sagittal profile), Modified SRS Outcomes Instrument (MSRSI). Secondary= estimated blood loss (EBL), operative time, complications

No significant difference at P<0.005 with student t-test unless indicated

Rib Hump: 16° posterior 17 ° anterior, corrected to 8 ° (50%) and 6 ° (60%) respectively.

Thoracic Cobb: 70° posterior 61 ° anterior, corrected to 27° (61%) and 22° (64%) respectively. No difference in preoperative curve flexibility or fulcrum bending correction index. Thoracic AVT 55% correction posterior, 70% anterior, Lumbar Cobb 59% correction posterior, 52% anterior. Thoracic kyphosis significantly reduced in posterior surgery (35 ° to 20 °) and significantly increased with anterior surgery (21° to 30°). Lumbar lordosis significantly reduced with posterior surgery (88° to 47°), no significant change with anterior surgery (60° to 53°).

MSRSI; Domain scores similar preoperatively between groups. Difference scores (postop-preop), higher scores=better. Pain: +1.21 posterior +0.73 anterior. Self image: +1.02 posterior +0.71 anterior. Function/activity: +0.28 posterior +0.21 anterior. Mental health: +0.66 posterior +0.45 anterior.

No significant difference in complication rate, operative time or estimated blood loss

Similar cohorts of AIS patients treated by either anterior or posterior surgery have no significant differences in radiological or functional outcomes. The different final sagittal profile in both groups did not affect the MSRSI outcomes. Both procedures deliver significant health gains as measured by the MSRSI.

A literature review of bone graft substitutes for spinal fusion was undertaken from peer reviewed journals to form a basis for guidelines on their clinical use.

A PubMed search of peer reviewed journals between Jan 1960 and Dec 2009 for clinical trials of bone graft substitutes in spinal fusion was performed. Emphasis was placed on RCTs. Small and duplicated RCTs were excluded. If no RCTs were available the next best clinical evidence was assessed. Data were extracted for fusion rates and complications.

Of 929 potential spinal fusion studies, 7 RCTs met the inclusion criteria for BMP-2, 3 for BMP-7, 2 for Tricalcium Phosphate and 1 for Tricalcium Phosphate/Hydroxyapatite (TCP/HA). No clinical RCTs were found for Demineralised Bone Matrix (DBM), Calcium Sulphate or Calcium Silicate. There is strong evidence that BMP-2 with TCP/HA achieves similar or higher spinal fusion rates than autograft alone. BMP-7 achieved similar results to autograft. 3 RCTs support the use of TCP or TCP/HA and autograft as a graft extender with similar results to autograft alone. The best clinical evidence to support the use of DBMs are case control studies. The osteoinductive potential of DBM appears to be very low however. There are no clinical studies to support the use of Calcium Silicate.

The current literature supports the use of BMP-2 with HA/TCP as a graft substitute. TCP or HA/TCP with Autograft is supported as a graft extender. There is not enough clinical evidence to support other bone graft substitutes.

This study did not require ethics approval and no financial support was received.

There is evidence that various anatomical structures have altered morphology with ageing, and anecdotal evidence of changing lumbar spinous process (LSP) morphology with age. This study aims to clarify the influence of age on LSP morphology, and on lumbar spine alignment.

200 CT scans of the abdomen were reformatted with bone windows allowing precise measurement of LSP dimensions and lumbar lordosis. Observers were blinded to patient demographics. Inter-observer reliability was confirmed.

The smallest LSP is at L5. The male LSP is on average 2-3mm higher and 1mm wider than the female LSP. LSP height increases significantly with age at every level in the lumbar spine (P<10^-5 at L2). The LSPs increase in height by 2-5mm between 20-85 years of age (P<10^-6), which was as much as 31% at L5 (P<10^-8). Width increases proportionally more, by 3-4mm or greater than 50% at each lumbar level (P<10^-11). Lumbar lordosis decreases in relation to increasing LSP height (P<10^-4) but is independent of increasing LSP width (P=0.2).

The height and width of the spinous processes increases with age. Increases in spinous process height are related to a loss of lumbar lordosis and may contribute to sagittal plane imbalance.

8 patients with cervical myelopathy treated by French-door laminoplasty and internal fixation. A novel technique of fixation is employed to provide immediate stability, pain relief and rapid mobilisation.

To report the clinical and radiological outcomes of this new fixation device for French–door laminoplasty with minimum follow-up of 30 months.

Hardware assisted laminoplasty has the potential advantage of instant stability and prevention of recurring stenosis. The use of titanium mini-plates has been described in open-door laminoplasty and now we describe this technique in French–door laminoplasty.

8 patients with cervical myelopathy secondary to congenital stenosis (2) and multi-level spondylotic myelopathy (6) underwent 2-4 level French–door laminoplasty and mini-plate fixation. The average follow-up was 46.5 months. Autogenous iliac crest bone graft was interposed between the sagittally split spinous processes and 16-18 holed titanium mini-plates were contoured into a trapezoidal shape and secured to the posterior elements with screws. Patients then mobilised without external support.

The mean follow-up was 46.5 months. The mean improvement in NDI at final follow-up was 35% and mean improvement in VAS was 4 points. JOA score improved from a mean of 10 to a mean of 14.8 post-operatively. All patients had achieved a significant neurological improvement and pain relief. There were no post-operative hardware related complications, pseudarthrosis or neurological deterioration.

French-door laminoplasty is an excellent alternative to laminectomy for treatment of young patients with cervical myelopathy. The use of titanium mini-plates not only provides instant stability and pain relief but also seems to minimize the risk of C5 nerve root palsy. Internal fixation appears to provide instant stability, early mobilisation and therefore reduces hospital stay and associated costs.

Osteoporotic vertebral deformities are conventionally attributed to fracture, although deformity is often insidious, and bone is known to “creep” under constant load. We hypothesise that deformity can arise from creep that is accelerated by minor injury.

Thirty-nine thoracolumbar “motion segments” were tested from cadavers aged 42-92 yrs. Vertebral body BMD was measured using DXA. A 1.0 kN compressive force was applied for 30 mins, while the height of each vertebral body was measured using a MacReflex optical tracking system. After 30 mins recovery, one vertebral body from each specimen was subjected to controlled micro-damage (<5mm height loss) by compressive overload, and the creep test was repeated. Load-sharing between the vertebral body and neural arch was evaluated from stress measurements made by pulling a pressure transducer through the intervertebral disc.

Creep was inversely proportional to BMD below a threshold BMD of 0.5 g/cm² (R²=0.30, P<0.01) and did not recover substantially after unloading. Creep was greater in the anterior cortex compared to the posterior (p=0.01) so that anterior wedge deformity occurred. Vertebral micro-damage usually affected a single endplate, causing creep of that vertebra to increase in proportion to the severity of damage. Anterior wedging of vertebral bodies during creep increased by 0.10^o (STD 0.20^o) for intact vertebrae, and by 0.68^o (STD 1.34^o) for damaged vertebrae.

Creep is substantial in elderly vertebrae with low BMD, and is accelerated by micro-damage. Preferential loss of trabeculae from the anterior vertebral body could explain greater anterior creep and vertebral wedging.

Patients with solitary spinal metastases from Renal Cell Carcinoma (RCC) have better prognosis and survival rates compared to other spinal metastatic disease. Adjuvant therapy has been proven ineffective. Selected patients can be treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to renal cell carcinoma.

Five patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology after pre-operative embolisation. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system.

Recurrence of spinal metastasis and radiological failure of reconstruction

All patients demonstrated full neurological recovery and reported significant pain relief. One patient died at 11 months post-op due to a recurrence of the primary. The other four are well at 24, 45, 52 and 66 months post-op without evidence of recurrence in the spine. There were no major surgical complications.

Careful patient selection is required to justify this procedure. The indication is limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence.

To investigate whether restoration of mechanical function and spinal load-sharing following vertebroplasty depends upon cement distribution.

Fifteen pairs of cadaver motion segments (51-91 yr) were loaded to induce fracture. One from each pair underwent vertebroplasty with PMMA, the other with a resin (Cortoss). Various mechanical parameters were measured before and after vertebroplasty. Micro-CT was used to determine volumetric cement fill, and plane radiographs (sagittal, frontal, and axial) to determine areal fill, for the whole vertebral body and for several specific regions. Correlations between volumetric fill and areal fill for the whole vertebral body, and between regional volumetric fill and changes in mechanical parameters following vertebroplasty, were assessed using linear regression.

For Cortoss, areal and volumetric fills were significantly correlated (R=0.58-0.84) but cement distribution had no significant effect on any mechanical parameters following vertebroplasty. For PMMA, areal fills showed no correlation with volumetric fill, suggesting a non-uniform distribution of cement that influenced mechanical outcome. Increased filling of the vertebral body adjacent to the disc was associated with increased intradiscal pressure (R=0.56, p<0.05) in flexed posture, and reduced neural arch load bearing (F_N) in extended posture (R=0.76, p<0.01). Increased filling of the anterior vertebral body was associated with increased bending stiffness (R=0.55, p<0.05).

Cortoss tends to spread evenly within the vertebral body, and its distribution has little influence on the mechanical outcome of vertebroplasty. PMMA spreads less evenly, and its mechanical benefits are increased when cement is concentrated in the anterior vertebral body and adjacent to the intervertebral disc.

Our study aims to evaluate the efficacy of Wallis implant in management of discogenic back pain.

We have prospectively studied thirty patients between 2006 and 2007. Average age of patients was 40.8 years. Average follow-up period 20.6 months (9-28). Main inclusion criteria includes failure of conservative management of low back pain due to degenerative disc disease, preservation of 50% of the disc height and positive discographic features. In majority of the patients the implant was put in at the level of L4-L5.

Pre-op and post op SF36 and Oswestry Disability Index (ODI) scores were assessed during clinic follow-up and by telephonic interview. Mean SF36 score improved from thirty-seven (8.3 – 54.3) to 51.4. Mean ODI improved from forty-three (20-60) to 26.5(2-60) (p = 0.026). Complications including superficial infection occurred in one patient, deep infection in one patient, erosion of spinous process in one and displacement of the implant in one case. Three (10%) patients had revision surgery due to various reasons.

Wallis interspinous dynamic stabilization system could be used as a soft stabilisation device avoiding fusion and short-term results are promising. In selected group of discogenic low back pain patients it is a useful interim procedure. Long-term follow-up of our series is ongoing.

To determine presenting features, treatment modalities and associated outcome following treatment of spinal dural arteriovenous fistulas in a tertiary centre.

Retrospective cohort study of patients with SDAVF assessed at a single tertiary referral centre, between 1999 and 2009. Medical records were used to identify intervention type, pre- and post-intervention Aminoff-Logue disability score (ALDS), recurrence rate, follow-up time and discharge status. Statistical analysis was performed using Wilcoxon signed rank.

26 patients were identified with 23 receiving intervention. Two were unavailable for follow up. Endovascular embolization was performed successfully in 13 patients, recurrence occurred in 6 of these, 3 of which were subsequently treated surgically. Surgery was the initial treatment for 10 patients due to either unsuccessful embolization attempt or proximity of the fistula to spinal artery feeders; only 1 of these recurred. ALDS-gait reduced (improved) by a mean of 0.33 points following intervention but this was not statistically significant (P=0.0645). There was negligible change in micturition and bowel ALDS. Improvement in ALDS was greater in patients treated with surgery first and also in patients whose fistula did not recur. Mean follow-up was 38 months with 56% of working age patients returning to work.

Both embolisation and surgery achieved the primary aim of reducing disease progression, leading to an improved ALDS. Outcome was superior if initially treated surgically and recurrence occurred more frequently in patients treated endovascularly. The small number of patients in our cohort emphasise the need for further studies into this group of patients.

AO Spine Reference Centre & Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, Australia

Traumatic spinal cord injury (SCI) is a devastating condition with no curative therapy. Pro-inflammatory therapy has been suggested recently to try and reduce the inhibitory glial scar and promote neural regeneration and healing. The aim of this study is to investigate the potential of sustained delivery of angiogenic/pro-inflammatory growth factors to reduce the secondary degeneration after spinal cord injury.

Adult male Wistar Kyoto rats (200-300g; 12-16weeks old) were subjected to cord hemisections via a T10 laminectomy. Animals were randomised to treatment or control groups after the spinal cord injury had been induced. Treatment consisted of implantation of a mini-osmotic pump capable of delivering 5 micrograms vascular endothelial growth factor (VEGF) and 5 micrograms platelet-derived growth factor (PDGF), via a catheter, to the site of the lesion, over 7 days(n=6). Control animals were subjected to either cord lesion only (n=6) or lesion plus mini-pump delivering PBS (phosphate-buffered saline) solution (n=6). Rats were sacrificed at one month and the spinal cords were harvested and examined by immunohistology, using anti-neurofilament-200 and anti-Glial Acidic Fibrillary Acidic Protein (GFAP) antibodies.

RESULTS: Active treatment spinal cords showed a higher level with aboration of the axonal filament through the defect and more dense neurofilament-200 staining at the lesion site compared to both control groups. The treatment also showed the elevated presence of activated microglia in the lesion, whilst distal to the lesion the microglia and astrocytes retained an unreactive phenotype.

Pro-inflammatory therapy in the rat spinal cord-injury model showed favourable histological findings after sustained delivery of PDGF and VEGF

To evaluate functional and oncological outcomes following resection of primary malignant bone tumours.

Primary malignant tumours of the sacrum are rare, arising from bony or neural elements, or bone marrow in haematological malignancies.

Management of these lesions is dictated by anatomical considerations and the behaviour of tumours. The three key issues which arise are the adequacy of tumour resection, mechanical stabilisation and the need for colostomy.

A retrospective review of the surgical management of primary malignant sacral tumours from 2004 - 2009.

The study included 46 patients (34 males, 12 females) with an average age of 49 (range 7 – 82). Median duration of symptoms before presentation was 26 months.

10 patients had inoperable tumours at presentation. 6 patients had chemotherapy. 2 patients opted for palliative radiotherapy. 1 patient was unfit for surgery.

25 patients (54%) underwent surgical resection. 8 underwent instrumented stabilisations with fibula strut graft vs. 17 uninstrumented.

Colostomy was performed in 10 patients (40%). Mean follow post-operatively was 19.0 months.

Wound healing problems were present in 5/25 (20%). There was no difference in infection rates between definitive surgery with and without colostomy. Mechanical failure of stabilisation was noted in 75%. There was one peri-operative death.

Local recurrence occurred in 12%(3/25) of operated patients although follow-up period was noted to be short.

Mechanical stabilisation for extensive lesions in the sacrum are particularly challenging in tumour surgery. Despite radiological failure in 7/8 instrumented stabilisations, patients were relatively asymptomatic and only 1/8 required revision stabilisation surgery.

Ethics approval: None: Audit Interest Statement: None

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.

Chondrosarcomas are uncommon primary malignant cartilaginous tumours, even less common in spine. Surgical excision is the only mode of successful treatment as these tumours are resistant to conventional chemotherapy and radiation therapy. We share our experience of 22 cases of chondrosarcomas of the spine with special reference to their recurrence and survival.

We identified 20 conventional and 2 dedifferentiated chondrosarcomas from the Scottish Bone Tumour Registry database between 1964 and 2009. Radiology and histopathology were documented. The mean follow-up was 5.2 years.

There were 14 men and 8 women with a mean age of 50.1 years. There were 7 under the age of 40 years (31.8%). The majority of lesions occurred in the thoracic spine (16), followed by sacrum (3), lumbar (2) and cervical spine (1). The overall local recurrence rate was 45.4% (10/22 cases-once in 5, twice in 2 and thrice in 3 patients).

Four patients presented with pulmonary metastases leading to death. The estimated overall 5- and 10-year survival rates were 31.8% and 18.1% respectively. We found that 1/3^rd of chondrosarcomas of the spine occured below 40 years of age and 3/4^th in the thoracic spine. Every other case was associated with local recurrence with a 32% 5-year and 18% 10-year survival rates.

Sacro-coccygeal chordomas pose a difficult diagnostic and therapeutic problem due to late presentation, large size, soft-tisue extension, difficulties in obtaining adequate resection margins, higher local recurrence rate and uncertain effectiveness of adjuvant treatment. We present a series of 21 patients of sacral chordomas obtained from Scottish Bone Tumour Registry to analyse predictors of local control and survival.

The clinical and morphologic features, type of treatment and follow-up of 21 consecutive patients with sacral chordoma were retrospectively reviewed and analysed. The data were obtained from Scottish Bone Tumour Registry.

The average age at time of the biopsy was 59 years (range, 12 to 82 years): twelve patients were male and nine were female. Pain was the presenting symptom in all patients. Two had intralesional (both recurred), 9 marginal (4 recurred) and 3 wide resections (1 recurred). Fifteen of the twenty-one patients were treated with adjuvant radiation therapy. In seven patients, the chordoma was inoperable and all but one were treated with adjuvant radiotherapy. Local recurrence and metastases occurred in 7 (50%) and 5 (23.8%) patients. The 5-year and 10-year survival were 38% and 14.2%, respectively.

Excision of the lesion combined with adjuvant radiation therapy provided satisfactory results. Local recurrence presents a major problem in the management of sacral chordomas (50%). Intralesional resection should be avoided as it is associated with 100% local recurrence in our series.

To quantify the duration of symptoms and the treatment modalities employed prior to surgery in patients undergoing lumbar and cervical nerve root decompression and to assess the evidence of these non-surgical treatments.

Pre- and post operative questionnaires completed by consecutive patients.

514 people undergoing consecutive cervical or lumbar nerve root decompression between March 2007 to October 2009.

Pre-operative severity and duration of pain, functional limitations and treatment received. Post-operative pain severity and change in functional limitations.

Evidence in the literature for efficacy of treatment modalities employed.

Mean duration of pre-operative symptoms was 23 months (range 1 to 360). 91% took regular medication for pain, 83% received one or more physical therapy, 24% received injection therapy.

There was improvement in both pain scores (mean pre-op 7.3; post-op 3.0) and 78% of the commonly reported functional limitations, walking, sleep and work.

We found extremely limited evidence to support the other treatment modalities employed.

Patients spend many months unnecessarily in pain, consuming considerable resources and may suffer significant side effects from ineffective treatment for pain emanating from nerve root compression. Surgical nerve root decompression relieves pain and restores function. Despite this a specialist opinion is often delayed. Early referral for specialist opinion is almost certainly more humane, cost effective, and time-limits the journey on the not so magic roundabout.

To assess radiological fusion rates in posterolateral fusions using SiS-CaP.

Retrospective, radiological follow-up study.

Single surgeon series of 76 consecutive patients were evaluated, in a regional spinal unit. All patients had clinical and radiological (MRI) spinal canal stenosis secondary to degenerative spondylosis or spondylolisthesis. Surgery consisted of instrumentation, decompression and meticulous preparation of the posterolateral graft bed by removal of all soft tissues posterior to the inter-transverse membrane and decortication of transverse processes (TPs). SiS-CaP putty was injected into this gutter and moulded around the instrumentation. Good quality, well prepared bone chips from the posterior decompression were seeded into the putty. Patient radiographs were reviewed at 3-6 months, 1 year and 2 years.

Radiographs were assessed using a protocol to examine granularity, bone formation and evidence of pseudarthrosis, based upon previously reported literature ¹ and our personal experience.

Of the 76 patients, 26 were excluded. M:F was 21:29. Mean age was 58yrs. Average number of motion segments fused per case was 2.2. There was one pseudarthrosis with metalwork fracture, and thus a total fusion rate of 98%. In addition, one patient had scanty bridging of TPs, and one patient had lucency around the S1 screws.

SiS-CaP, as a bone graft substitute in posterolateral instrumented fusions, gives comparable results to published fusion rates using autologous iliac crest grafting and/or Bone Morphogenic Protein ². Moreover, it avoids the associated morbidity of iliac bone harvest.

To review the accuracy of our systematic process in preventing wrong level lumbar microdiscectomy.

X-ray is used to identify the correct level for the skin incision to be made, x-ray is again used if the surgeon is in doubt prior performing the flavotomy. Following a lumbar microdiscectomy a Watson Chane is inserted into the empty disc space and an intra-operative x-ray is taken to confirm the level the discectomy has occurred. Observers A and B independently reviewed intra-operative x-ray in patients undergoing lumbar microdiscectomies and correlated the accuracy of the x-ray in determining correct level surgery against the pre-operative MRI scan and the preposed level of surgery.

123 patients, 66 males and 57 females underwent 127 lumbar microdiscectomy procedures between 2007 and 2009. The levels where surgery occurred are;- L2/3 -1 patient, L3/4–8 patients, L4/5–53 patients and L5/S1-65 patients.

Kappa coefficient was used to determine inter-observer and Pearson Correlation coefficient was used to determine the X-ray and MRI relationship

Percentage of patients who required a pre-flavotomy x-ray level check are:- L2/3–100%, L3/4-63%, L4/5–45%, and L5/S1–40%. Pearson's correlation in confirming the level lumbar microdiscectomy was performed using final x-ray and the pre-operative MRI scan was 1. Kappa coefficient between observer A and B was 1.

This process of using intra-operative x-ray in determining the exact level where lumbar microdiscectomy was performed is 100% accurate. This is our standard process in preventing wrong level surgery for lumbar microdiscectomy.

To determine if there is a safe osseous corridor for trans-sacroiliac screw fixation of U-type sacral fractures using fluoroscopic landmarks.

We reviewed the sacral anatomy of patients who underwent Computed Tomography (CT) investigations between October and December 2009. Agfa-IPMAX Version 5.2 software was used to determine if there was a trans-sacroiliac osseous corridor in the S1 and S2 vertebrae from one ilium to the other.

76 patients were in the study, 38 male and 38 female. Exclusion criteria were patients under 18 years old; patients with degenerate lumbar spine and lumbo-sacral junction; CT imaging slices greater than 2.5mm.

We measured various parameters including the dimensions of the S1 and S2 mid-sagittal vertebral body; cross-sectional areas of the S1 and S2 corridor; location of the centre of the S1 and S2 corridor.

The mean cross-sectional area for S1 and S2 corridors in males and females are 21mm² and 15mm² respectively. The mean cross-sectional area for the S2 corridor in males and females were 15mm² and 11mm² respectively. The centre of the S1 and S2 corridor is located in the centre of both S1 and S2 vertebrae.

Two-thirds of males and females have a complete osseous corridor to pass a trans-sacroiliac S1 screw. The S2 corridor was present in all males but only in 87% of females. Before placement of trans-sacroiliac screws, the surgeon should review the CT sacral anatomy to determine if the trans-sacroiliac osseous corridor is present.

Ethics Approval: None – Audit Interest Statement: None

We have examined how many and which potential complications (PCs) are recorded on the consent form by a group of consultant surgeons performing common spinal procedures - anterior cervical discectomy and fusion (ACDF) and posterior lumbar discectomy and/or medial facetectomy (PLD).

Email survey

Consultant spinal surgeons performing ACDF and/or PLD practicing in Southwest England

Identification of the PCs each surgeon listed on the consent form for the specified procedures.

There were 23 responses from 28 Consultant surgeons approached. 21 surgeons performed both ACDF and PLD, 2 performed only PLD. Surgeons quoted 5 to 17 (mode 10) PCs for ACDF and 4 to 15 (mode 13) for PLD. These did not necessarily represent the most common or most dangerous PCs recorded in the literature^1,2. Small difference in PCs mentioned by Neurosurgeons and Orthopaedic surgeons was seen (ACDF mode: 12vs10, PLD mode: 12vs13). There was a strong correlation between the number of PCs recorded by surgeons for ACDF and PLD.

We have found a wide variation in consenting practice amongst a group of surgeons performing common spinal operations. Issues of consent are common causes of formal complaints and potential litigation, causing anxiety for both patient and surgeon. A more homogenous consent process, employing objective measures where possible, may help reduce this burden and may be achieved by setting a national standard.

To establish whether incidental durotomy complicating lumbar spine surgery adversely affects long-term outcome.

Data was collected prospectively. The study population comprised 200 patients. 19 patients who sustained dural tears (Group A) were compared to a control group of 181 patients with no tear (Group B). Outcomes were measured with the SF-36, Oswestry Disability Index (ODI) and visual analogue scores for back (VB) and leg (VL) pain. Scores for the 2 groups were compared pre-operatively, at 2 and 6 months post-op for all patients and at long-term follow-up (range 2-9 years) for patients in group A.

In addition for patients in group A the patients satisfaction with the procedure, ongoing symptoms, employment status and analgesic intake were documented

Pre-operative scores were similar between the 2 groups apart from significantly higher vb scores (63 –A vs 46-B). Results at 2 and 6 months showed no significant differences between the 2 groups. Outcome scores for group A at long-term follow-up do not show any significant decline.

Our study demonstrates that incidental dural tears complicating lumbar spine surgery do not adversely affect outcome in the long-term

To assess whether Patients who are clinically Obese are more likely to require further or revision Surgery following One-Level simple Microdiscectomy compared to Non-obese Patients.

Retrospective, single centre and single Surgeon review of Patients' Clinical notes of consecutive Patients who underwent primary One-Level Microdiscectomy between December 2007 and July 2009.

Background: Obesity in Surgery has become a topical subject given the increasing proportion of Surgical Patients being Obese. This study provides the largest single centre and single Surgeon comparative cohort.

All Patients had undergone One-level simple Primary Microdiscectomy Surgery. Data from the Clinical notes included Patient Demographics, level and side of operation, Length of stay and Re-Operation details. A total number of 71 Patients were eligible for inclusion of which 38 were Female and 33 Male with an average age of 41 years. 25 Patients were Clinically Obese (35%). Average LOS was 1.1 days. 8% of the clinically Obese Patients required further Surgery compared to 8.7% in the Non-obese group.

Revision surgery for recurrent discs and Surgery for dural tear repair were the main reasons for return to theatre. Revision rates were comparable between the two Patient groups. LOS was no different for Obese Patients. This study concludes that Obese Patients undergoing One-Level simple Microdiscectomy do not face a significantly higher risk of requiring Revision Surgery in the future.

The aim of this study is to review the functional outcome of the patients treated with Posterior Lumbar Interbody Fusion for FBSS.

This is a retrospective review of prospectively collected data of 39 patients diagnosed with FBSS and treated with PLIF between June 2000 and December 2008 by the senior author in our unit. Pain and function were evaluated by VAS for Back (VAS-BP) & leg pain (VAS-LP), Oswestry disability index (NDI) and SF-36 questionnaires, and were completed pre- & post-operatively.

There were 39 patients (20 women & 19 men) and mean age at operation was 47.3 years (range of 32 to 76.1 years). Mean duration of follow-up was 39.14 months (range 5.21 -73.5 months). Thirty-one patients were diagnosed as Post laminectomy syndrome and 8 patients as post-discectomy syndrome.

The mean pre and post-operative ODI values were 54.13 and 29.14 respectively. The mean pre-operative VAS back and leg pain scores were 7.38 and 6.51 respectively. The mean post-operative VAS for back and leg pain scores were reduced to 4.05 (Pre-op:7.38) and 3.69 (Mean pre-op 6.51)respectively. The mean preoperative SF-36 bodily pain component score was 27.42 and the mean postoperative score was 40.50.

Four patients had uncomplicated dural tears that resolved completely. Two patients had superficial wound infection that resolved with oral antibiotics.

PLIF is one of the safe and effective treatment option for FBSS and it has shown good results in our series.

The revised Tokuhashi score has been widely used to evaluate indications for surgery and predict survival in patients with metastatic spinal disease. Our objective was to determine whether the score accurately predicted survival in those with MSCC.

Retrospective analysis

All patients with MSCC presenting to our unit were included in this study from October 2003 to December 2009. Patients were divided into three groups – Tokuhashi score 0 – 8, 9 – 11 and 12 -15.

Neurological outcome and survival

A total of 109 patients with MSCC were managed in our unit during this time. Mean age of patients was 61 years (range 7 - 86). Mean and median survival was 350 (5-2256) and 93 days in the 0-8 group, 439 (8-1902) and 229 days in the 9-11 group, and 922 (6-222) and 875 days in the 12-15 group; p = 0.01. All patients underwent decompression and stabilisation surgery.

The rate of consistency between the prognostic score and actual survival was 64% (0-8), 64% (9-11) and 69% (12-15). Overall the consistency was 66%.

There was no difference in neurological outcome between the 3 groups.

There was a significant difference in the mean survival between groups. There was a moderate consistency between predicted and actual survival in this group of patients who all had cord compression. All patients had undergone some form of decompression and stabilisation surgery regardless of the overall revised Tokuhashi score.

To assess whether the timing of surgery is an important factor in neurological outcome in patients with MSCC.

Retrospective review

All patients with MSCC presenting to our unit were included in this study from October 2003 to December 2009. Patients were divided into three groups - those who underwent surgery within 24 hours (Group 1), those 24 hours to 48 hours (Group 2) and those greater than 48 hours (Group 3).

Neurological outcome (improvement in Frankel score), complication rate and survival were assessed in all groups.

A total of 109 patients with MSCC were operated on in our unit during this time. Mean age of patients was 61 years (range 7 - 86).

The number that had at least one grade of Frankel improvement was 21 /37 (57%) in group 1; 11/17 (65%) in group 2 and 20/49 (41%) in group 3, p=0.03.

When patients treated less than 24 hours were compared with those greater than 24 hours, the Frankel grade improvement approached significance (p=0.05).

When we compared those who had surgery within 48 hours and those greater than 48 hours, the Frankel grade improvement was highly significant (p=0.009).

There was no difference in survival or complications between the groups.

Our results suggest that early surgical treatment in patients with MSCC gives a better neurological outcome but has no influence on survival or complication rates.

The aim of this study was to review the data held with the NHSLA database over the last 10 years for negligence in spine surgery with particular focus on why patients ‘claim’ and what is the likely outcome.

Anonymous retrospective review

We contacted the NHSLA and asked them to provide all data held on their database under the search terms ‘spine surgery or spine surgeon.’

An excel sheet was provided, and this was then studied for reason of ‘claim’, whether the claim was open/closed and outcome.

A total of 67 claims of negligence were made against spinal surgeries during this time (2000-09). The number of claims had increased over the last few years: 2000-03, n= 8, 2004-06, n= 46. The lumbar spine remains the most common area (Lumbar: 55/67, Thoracic : 6/67, Cervical 6/67). Documented reasons for claims were post-operative complications (n= 28; 42%), delayed/failure to diagnose (n=24; 36%), discontent with preoperative assessment including consent (n=2; 3%), intra-operative complications (n= 10; 15%) and anaesthesia complication (n=3; 4%).

Twenty were closed and 47 remained open. The number of successful claims was 8/20 (40%). The mean compensation paid out was £33,409 (range was £820.5 to £60,693).

The number of claims brought against spinal surgeries is on the increase, with the most common area being the lumbar spine which perhaps is not surprising as this is the most common area of spinal surgery. Common reasons are post-operative complications and delay/failure to diagnose. The ‘success’ of these claims over the last 10 years was 8/20 (40%) with mean compensation paid out was £33,409.

Ethics approval: None;

Interest Statement: The lead author is the CEO and founder of a Personal Injury/Medico-Legal company

Establish the prevalence of B12 deficiency in patients presenting for surgical assessment and to audit subsequent management.

Retrospective: The pathology database was interrogated for all B12 and folate requests under the name of a Spine sub-specialty Consultant over a four year period (2005-2008). 38 patients with B12 deficiency were identified.

Patient self reported symptoms, drug history, Global outcome score (Much better, better, same, worse) Visual Analogue Score (VAS) and Oswestry Disability Index(ODI).

458 tests occurred. 38(8.3%) were B12 deficient. Of these, 10 (26%) had received no treatment at review.

Average age 63 years. 23 males, 15 females. 6 patients were diabetic. At clinic attendance Mean ODI 46%; VAS(leg) 6.4. A sample from those with a normal B12 had ODI 45%; VAS(leg) of 5.9.

Of the three who were “worse”, one had been treated. 7 of the 12 patients who felt the “same” had received injections. 9 were “better” with 5 on supplements. Five were “much better” with all patients on supplements.

Less than half(47%) were prescribed analgesia, 11 out of 38 were taking paracetamol, 6 were prescribed NSAIDs, 6 opiates, and 10 were taking neuropathic painkillers.

Reversible causes of neuropathic pain can only be identified by testing. A high index of suspicion resulted in positive tests in 8% of the population studied. Administrative obstacles exist to treatment. Those that are treated do better. Sensory symptoms in a spine clinic patient should not be assumed to originate exclusively from the spine.

Audit/service standard registered in Trust No conflict of interest

The use of nerve root blocks is common in the management of radicular pain due to lumbar disc prolapse. However, most papers reporting their use do not necessarily specify the position or level at which the needle is positioned with respect to the level of pathology. We therefore set out to investigate this. We performed a survey of medical practitioners across the UK with an interest or involvement in the management of radicular pain secondary to lumbar disc prolapse The survey depicted the clinical scenario of a patient with radicular pain from an L4/5 disc prolapse and a number of questions were asked in relation to the use of nerve root blocks.

Questionnaires were sent to 319 practitioners. We received 153 responses of which, 120 (37.6%) were sufficiently complete to be analysed. Of those who responded, 83% used a combination of local anaesthetic and steroids together with or without contrast. There were variations across the respondents in terms of the level injected with 22.5% injecting at the level of the L4/5 foramen, while 45% injected at the level of the L5/1 foramen. Differences were also noted when respondents were subgrouped according to their speciality. Of those who worked in pain management, 34.1% injected at the L4/5 foramen while 31.8% injected at the L5/1 foramen. For spine surgeons the respective figures were 20.5% and 43.2% and for radiologists 9.4% and 65.6%.

In the treatment of radicular leg pain, there are apparent variations in the use and positioning of root blocks for a given level of disc pathology. This suggests that caution is necessary when considering the validity of published studies on the use of root blocks relative to an individual clinician's practice.

To evaluate the patient experience of patients referred to the ESP Orthopaedic Triage Service. To identify the demographic data of the patients

To evaluate patients' expectations and satisfaction of the service

A prospective audit of 50 new patients to the ESP service in Mountain Ash General Hospital and Prince Charles Hospital

The audit was carried out over a 3 month period between December 2008 and February 2009.

Patients were asked to anonymously complete a survey following their appointment. Data was collated independently and analysed with descriptive statistics.

Patients referred to ESP service

Self administered satisfaction survey.

Mean age range 40-59 yrs (range 20 -70yrs). 50% >1 year duration of symptoms.

94% of patient's surveyed rated the service provided as good - excellent. 88% of patient's reported that they were happy to be assessed by the ESP.

96% of patients surveyed agreed they were able to discuss their treatment openly with only 10% preferring to see a Doctor.

The ESP service in Cwm Taff Health board achieves a high level of patient satisfaction.

To establish the incidence of litigation in Cauda Equina Syndrome (CES) and the causes of litigation.

Review of 10 years of abbreviated records of the National Health Service litigation authority (NHSLA) (1997-2007) and eight years of medical negligence cases (MNC) reported on by the two senior authors (2000-2008).

Patients who experienced CES and litigated. There were 117 patients in the NHSLA records and 23 patients in the MNC group.

Review of timing of onset, delay in diagnosis, responsible specialist, place, and resulting symptoms

NHSLA cases. 62/117 cases were closed. The responsible specialists were as follows

The commonest failure was delay in diagnosis, and the commonest complications were “neurological”, bladder and bowel.

MNC cases. F:M;17/6. L4/5 13 cases, L5/S1 9 cases. The responsible specialist was orthopaedic (7), other (7) and in 8 cases the opinion was that there was no case to answer. Delay to treatment averaged 6.14 days. 18/23 patients described bowel and bladder symptoms, the information was not available in the remainder.

Litigation is major problem in CES. In most cases orthopaedic surgeons are litigated against, and bowel and bladder symptoms remain the most disturbing cause of litigation. These surgeons are mostly not spinal specialists. In most successful cases of litigation there is considerable delay in diagnosis and management. Where there is incomplete Cauda Equina Syndrome urgent or emergency investigation and treatment is mandatory.

Spinal Deformity Service, Royal Orthopaedic Hospital, Birmingham, UK

To describe the technique of nonfusion annulotomy and nuclectomy with posterior growing rod instrumentation for the treatment of non-congenital early onset scoliosis

To present our results of the application of this technique in a consecutive series of nine patients with mean follow up of 76 months (range 16 to 123 months)

We undertook retrospective observational casenote and radiograph study of patients with noncongenital early onset scoliosis having annulotomy and nuclectomy at the apex of their respective curves with standard posterior growing rod instrumentation between 1998 and 2009.

10 patients were identified with one excluded due to short follow up period. Of the nine patients included mean follow up was 76 months. Mean age at primary surgery was 71.7 months (range 29- 97 months)

We measured pre and post operative Cobb angle, T1-S1 height change and change in height over the apical segments.

Mean pre op cobb angle was 74° (range 62- 81°). Mean post op cobb angle was 38°. Three patients have completed their treatment programme with a mean number of 9 lengthenings achieved. Six patients are still undergoing lengthenings. CT demonstrates that the annulotmized segment does not fuse at a mean 3.5 years postoperatively. All patients demonstrated growth over total spinal height and also over apical segments which had undergone annultomy/ nuclectomy. We also report complications.

We have demonstrated that anterior annulotomy and nuclectomy with posterior growing rod construct does allow for spinal growth over released segments without autofusion.

To determine the factors that influences the clinical outcomes in surgical correction of thoracic AIS.

There are conflicting data regarding the effects of back shape and radiologic parameters on the self-reported outcomes of surgery in AIS.

Prospective, cohort study; mean follow-up 29 months (range 9-88)

30 patients (5 males);

Rib hump 17 ° corrected to 7 °.

Thoracic Cobb 66 ° corrected to 25 ° (63%). Lumbar Cobb 42 ° corrected to 17°. Thoracic apical vertebral translation (AVT) 48mm corrected to 18mm. Lumbar AVT 34mm corrected to 19mm. Thoracic kyphosis 29° preoperatively 23° postoperatively. Lumbo-sacral lordosis 57° preoperatively 49° postoperatively

Modified SRS Outcomes Instrument (MSRSI) filled out pre-operatively and at final follow up.

Primary= rib hump, radiological (frontal Cobb correction, lumbar & thoracic AVT, sagittal profile), Modified SRS Outcomes Instrument (MSRSI) domain scores.

The magnitude of the rib hump had a significant association with pain:

Rib hump vs. MSRSI pain r= -0.55 p<0.000

Similar correlations existed between rib hump and self-image (r=-0.64, p<0.0000), thoracic Cobb angle with pain (r=-0.48 p<0.0001) and self-image (r= -0.57, P<0.0000). The postoperative thoracic Cobb angle, and percentage thoracic Cobb correction had significant correlations with self-image (r=-0.55 p=0.003 & r=0.54 p0.004 respectively).

The size of the rib hump has a significant impact on pain & self-image. These domains are also significantly influenced by the residual thoracic Cobb angle and overall scoliosis correction.

To determine if the term “back pain” has uniform meaning to spinal surgeons.

A survey of specialists attending an international meeting on spinal surgery. Participants were shown 5 schematic pain drawings and then asked to categorize the pain as either back or leg pain.

An international cohort of neurosurgeons, orthopaedic surgeons and trauma surgeons (n=104) attending a European spinal meeting.

67% of participants were orthopaedic surgeons and 22% neurosurgeons. 42% were in full time spinal practice. 50% had been in independent practice for 7 years or more. There was no statistical difference in the responses of neuro- and orthopaedic surgeons (Fisher's test, p>0.05).

The more rostral the pain, the more likely it was to be deemed “back pain”. However, unilateral pain was more likely to be deemed “leg pain” than its bilateral symmetrical equivalent no matter how rostral the distribution. Unilateral mid-lumbar pain was considered “back pain” by 48%, symmetrical bilateral mid-lumbar pain in 87%. Pain in the buttocks was considered “back pain” in 50% whether unilateral or bilateral.

This study demonstrates significant discrepancy in what is considered to be back pain and leg pain by a broad spectrum of spinal surgeons. Back pain and leg pain are often investigated and managed in different ways. This differentiation is difficult to justify until we know the answer to the question, what is back pain?

Assessment of long term results of Chemonucleolysis vs. surgical enucleation in soft disc herniation

From 1982 to 1985, 100 patients with symptomatic disc herniation were randomly allocated to receive either Chemonucleolysis or disc enucleation after all these patients had a trial of conservative treatment for three months.

The outcome of result was measured using MacNab Criteria with the help of

Questionnaire

Assessing the patients in clinic

44 patients out of original 100 patients were followed up in the clinic 25 years later. 24 were from chemonucleolysis group and 20 from the surgical group.

According to MacNab criteria 62.5% had excellent or good results and 25% poor results in chemonucleolysis group and in surgery group 70% had excellent or good results and 10% poor results. Patients with poor result in Chemonucleolysis group consisted of: a) 1 had poor result post TKR, b) 4 were offered surgical enucleation subsequent to failed Chemonucleolysis though they did not seem to benefit from surgery and 1 out of these 4 also had fibromyalgia. c) 1 had poor result after sustaining fracture neck of femur. Poor results in surgical group were due to persistent back pain.

The results at 25 year follow-up have shown no statistically significant difference between the patients treated by either chemonucleolysis or surgery. The added benefit of using the chymopapain injection is that it is of lower cost. Chemonucleolysis should have a wider role in treatment of intervertebral disc herniation.

To analyse if patients with pain improvement following a nerve root block had better outcomes following lumbar microdiscectomy.

Fifty-six patients who had a lumbar microdiscectomy were retrospectively followed up to 1 year. All patients had a selective nerve root block (SNRB) as a primary treatment or diagnostic procedure. VAS pain scores were measured daily for 1 week following injection. Patients were grouped into responders and non-responders at 1 week. The 2 groups of patients were followed at 1 year following a lumbar microdiscetomy (LMD).

A total of 118 patients had SNRB over a period of 3 years. Of the 56 patients studied retrospectively, 52% and 36% of patients had a VAS score improvement of more than 2 points at 4 days and 1 week respectively. At 1 year post op, 85% of patients had better outcomes in the responder group compared to 74% in the non responder group. Although there was a difference this was not statistically significant.

Improvement with SNRB is not a positive predictor of good response with surgery. The ability to evaluate the effect of diagnostic or therapeutic blocks on surgical outcomes is limited by a lack of randomized studies and wide-ranging discrepancies with regard to injection techniques, surgical technique, and outcome measures. More research is needed to determine if diagnostic screening blocks can improve surgical outcomes.

Standard approaches to thoracic intradural tumors often involve a large incision and significant tissue destruction. Minimally invasive techniques have been applied successfully for a variety of surgical decompression procedures, but have rarely been used for the removal of intradural thoracolumbar tumors. Here we compare the clinical outcome of mini-open resection of intradural thoracolumbar tumors to a standard open technique.

We retrospectively reviewed our series of twelve mini-open thoracolumbar intradural tumor resection cases and compared the outcome to a profile matched cohort of six cases of open intradural tumor resection cases. Operative statistics, functional outcome, and complications were compared.

Tumours were extirpated successfully with both approaches. There was no statistical difference in operating times, ASIA score improvement, or back pain VAS score improvement between groups. However, the mini-open group had a statistically significantly lower estimated blood loss (146 cc vs. 392 cc) and a significantly shorter length of hospitalization (3.6 vs 7.8 days). There was one complication of pseudomeningocoele formation in the mini-open cohort and no complications in the open cohort. Mean follow-up length was 13 months in the miniopen group compared to 23 months in the open group.

The mini-open approach allows for adequate treatment of intradural thoracolumbar tumors with comparable outcomes to standard, open approaches. The mini-open approach is associated with a lower blood loss and a shorter length of stay compared with standard open surgery.

Review the complications reporting in 4 prominent spinal journals over the last decade.

Computerised search of the Medline database and hand search was undertaken to evaluate the complication reporting in 4 spinal journals (Spine, European Spine Journal, Journal of Neurosurgery Spine and Journal of Bone and joint surgery) from 2000 to 2009. The articles were divided based on the level of NICE evidence classification A to D.

A total of 88 articles reported spinal complications. Of these 5.9% was level B, 8.8% was level C and 85.3% was level D. There were no RCT's reported relating to complications (Level A) and majority of complications were case reports or expert opinions (level D). For the proportion of level D the rank order of the journals was; Spine (4.8%), European spine journal (3.8%), Journal of neurosurgery spine (5.1%) and Journal of bone and joint surgery was (1.8%). There was no increase in the rate of reporting over the decade. A detailed discussion of the reporting will be presented.

Papers focusing primarily on complications and its management are still not the focus in most surgical journals. This review over the last 10 years confirms that only rare and uncommon complications are reported in the form of case reports. Meta analysis or case series of complication is rarely reported. More focus must be emphasised on reporting mortality and morbidity for education.

Retrospective analysis of radiology reports of conventional MRI in 100 patients with definite spinal stenosis to determine the incidence of reported “foraminal stenosis”.

Prospective study of MRI including T2 coronal and T2 STIR coronal sequences in 57 patients with suspected stenosis. Three surgeons and one radiologist independently compared the diagnoses on conventional and coronal scans.

Patients with suspected spinal stenosis undergoing MRI.

Incidence of “foraminal stenosis” on radiologists' reports.

Diagnoses obtained by different scanning methods.

Retrospective analysis: “foraminal stenosis” called by radiologists in 46% using conventional axial and sagittal sequences.

Prospective study - 57 patients: conventional sequences diagnosed lateral recess stenosis well but also suggested foraminal stenosis in 33%. However, coronal sequences clearly showed no foraminal nerve compression.

In degenerative spondylolisthesis conventional scans suggested foraminal stenosis in 8 of 11 cases. Coronals showed no foraminal stenosis.

Excellent correlation was found in normal spines and in disc herniation. In far lateral disc herniation and isthmic spondylolisthesis, true foraminal stenosis was confirmed by conventional and coronal imaging.

Additional coronal MRI sequences prove that foraminal stenosis is over-diagnosed and is rare in spinal stenosis, but true foraminal nerve compression occurs in isthmic spondylolisthesis and far lateral disc herniation.

Surgery of the spine is associated with blood loss and frequently transfusion, with consequent risk of infection and reactions. It also costly, and puts a strain on national blood banks.

A new blood salvage device works by ‘washing’ and centrifuging the blood lost during surgery; which can then be re-transfused into the patient.

In a retrospective study 46 consecutive spinal surgeries with Cell Saver were compared with 39 matched surgeries without. Blood loss and units transfused was obtained from the transfusion database and the anaesthetic record.

Average blood loss in the Cell saver group was 1382ml compared to 1405ml in the pre-Cell Saver group.

Average allogenic transfusion was 1.30 units with cell saver compared to 2.78 units without. An average 2.3 units of lost blood were re-infused in the Cell Saver group.

26 (57%) of the Cell Saver group require no allogenic blood at all, whereas only 10 (26%) of patients in the pre-Cell Saver group had no transfusions.

One unit of blood costs £130.52, and the Cell saver device costs £100 per patient. The average cost per patient in the Cell saver group was £270 (any transfusion plus cost of Cell Saver), compared to an average of £368.50 in the pre-Cell Saver group: a saving of £92.50.

The Cell Saver decreased blood transfusions by 46% per patient and by 40% overall, a saving of £92.50 per patient. The number of patients receiving no allogenic blood increased by 31%.

Back pain is extremely common in soldiers undergoing training¹. There is no data worldwide with regards to incidence, prevalence and impact of back pain in a deployed military population. This study was undertaken to evaluate these issues.

1000 back pain questionnaire were distributed over a period of four days at the main military base in Basrah in February 2009 in different locations. The filling out was anonymous and completely voluntary.

UK military personnel

Information was obtained about age, BMI, length of service, rank, incidence, prevalence, onset, admission rate, treatment, aero-medical evacuation, operational effectiveness, pain killers and VAS.

768 (77%, 26% of population at risk) questionnaires were returned Prevalence of back pain was 33.4% (257). A greater prevalence occurred in the combat arms (41.7%, p=0.01) and those of over 12 years service (44%, p=0.004). No statistical difference was found with rank, or BMI. 74 people (9.6%) had developed new onset back pain since deploying. Recurrent pain occurred in 38.9% of the whole sample. VAS showed a normal distribution. 35% of those affected were discharging their duty with mild difficulty but around 6% were having great difficulty. 25% were on regular analgesics. Back pain constituted 23% (137/583) of the physiotherapy dept caseload, 6.6%, (25/378) of ward admissions and 0.04% (5/119) of aero-med patients.

Back pain is a major problem among deployed personnel. However with adequate resources the vast majority can be managed in the field thus reducing attrition rates² and maintaining operational effectiveness. Further studies should be undertaken to assess if back pain persists after deployment.

There are many various possibilities of treatment from observation and conservative treatment, over simple bony fusion to exacting hemivertebrectomies and deformity correction.

Retrospective analysis of various conservative and surgical techniques.

Subjects. The total number of 702 patients treated in our department since 1976 had been evaluated. An average follow up is 17 years.

Correction grade, security and efficiency of treatment methods, clinical results and complication rate were the main observed outcome measures.

Group A (conservative treatment) - 356 pts.

Group B (hemiepiphyseodesis) – 112 pts. Final result of correction was 9,8 degrees (22%).

Group C (posterior instrumentated fusion) – 147 pts. Final result of correction was 25,6° (38%).

Group D1 (anterior strut graft with posterior instrumentated fusion) – 27 pts. Final result of correction was 26° (40%).

Group D2 (anterior osteotomy with posterior instrumentated fusion) – 33 pts. Final result of correction was 28° (43%).

Group D3 (combined hemivertebrectomy with posterior instrumentated fusion) – 22 pts. Final result of correction was 31,3° (61%).

Group D4 (posterior only hemivertebrectomy with instrumentated fusion) – 5 pts. Final result of correction was 30,7° (61%).

Early detection, good timing and choosing of adequate surgical type are the main factors of quality treatment results. The best surgical method for formation failure types seems combined or posterior only instrumentated hemivertebrectomy and early hemiepiphyseodesis for segmentation failure types.

To analyse procedural details - specifically vertebral levels treated and injected polymethylmethacrylate (PMMA) volumes - of the publications by Buchbinder et al. ¹ and Kallmes et al. ² in the context of best available basic science.

Review

Two randomised controlled trials published by the New England Journal of Medicine (NEJM) in 2009 comparing vertebroplasty to sham procedures conclude vertebroplasty to be no more effective than injection of local anaesthetic. This finding contradicts previous publications showing clinical efficacy.

Neither investigation provides a breakdown of vertebral levels treated (original publication and supplementary material). Only one investigation provides information on fill volumes with average of 2.8 ml +/− 1.2 ml SD.

The available basic science indicates a minimum fill volume of 13-16% of the vertebral body volume to be necessary for a relevant biomechanical effect on restoration of vertebral strength, according to which only vertebrae of the upper to mid thoracic spine could reasonably have received a biomechanically effective fill with the declared average volume of 2.8 ml +/− 1.2 ml SD.

The available data of the NEJM publications strongly indicates that the treatment arm includes insufficiently treated patients. The technical information provided by the NEJM publications is insufficient to conclusively prove or disprove the clinical efficacy of vertebroplasty.

It was noted that in our spinal theatre a constant cause of delay was lack of an available radiographer. This work describes our solution to this problem by training theatre staff to operate the imaging equipment for the simple single plane images required in spinal surgery.

Under the guidance of the trust's Radiation Protection Advisor to a training program for theatre staff was devised that encompassed the practical aspects of using the imaging equipment and the theoretical elements of radiation safety. All changes in practice complied with the radiation safety regulations IRR 99 and IRMER 2000.

The trained staff now work as independent operators in the spinal theatre. They work to a ridge protocol and have to report directly to a Radiation Protection Supervisor (senior radiographer) at the end of each list so that the images taken and radiation dosage can be verified.

Since the change of practice, the spinal theatre has been more efficient, performing up to one major case extra per list. The radiology department has benefited by having a radiographer freed to perform more complex procedures elsewhere. The operators have also commented on how they have found the whole process rewarding both professionally and personally.

The training of theatre staff to operate the imaging equipment in our spinal theatre has been a successful endeavour and at present the trust is currently planning to expand the program to include other surgical fields such as urology and laparoscopic surgery.

Auckland City Hospital, Auckland, New Zealand.

To show that the spinous processes (SPs) increase in size with age.

To investigate the incidence of SP abutment, relationship to disc degeneration and age related kyphosis.

Describe patterns of SP neoarticulation in relation to back pain and intersegmental axial rotation and deformity.

We reviewed 200 Abdominal CTs, CT myelograms and 100 standing x-rays (age 18-90 years).

We measured SP size, interspinous gap, patterns of neoarticulation, disc height, lumbar lordosis and axial rotation.

We compared symptomatic and asymptomatic groups.

A 30-50% increase in SP size coupled combined with a loss of disc height leads to increasing rates of SP abutment after the age of 35 years. 30% of people over the age of 60 years have SP abutment.

There is a 15 degree increase in standing lumbar kyphosis with age.

Four patterns of SP neoarticulation are seen. Degenerative changes in the SP articulation increase by more than 80% in a symptomatic cohort.

Oblique SP articulation is 2.5 times more likely in symptomatic individuals and associated with a rotational intersegmental deformity.

Ageing is accompanied by SP enlargement and abutment, contributing to a loss of lumbar lordosis.

Patterns of neoarticulation and degeneration appear associated with back pain and rotational deformity.

Plain radiography has traditionally been used to investigate and monitor patients with adolescent idiopathic scoliosis. The X-ray allows a calculation of the Cobb angle which measures the degree of lateral curvature in the coronal plane. ISIS2 is a surface topography system which has evolved from ISIS, but with much higher precision and speed. It measures the three dimensional shape of the back using structured light and digital photography. This system has the benefit of not requiring any radiation. Lateral asymmetry is the ISIS clinical parameter estimating the curve of the spine in the coronal plane. The aim of this study was to compare this parameter to the Cobb angle measured on plain X-ray.

Twelve patients with idiopathic adolescent scoliosis underwent both a standing AP spine X-ray and an ISIS2 scan on multiple occasions. Both scan and X-ray were done within one month of each other. No patient underwent surgery during the study period. The Cobb angle and the degree of lateral asymmetry were calculated.

Twelve patients mean age 12.5 years (range 10-16) were investigated using both ISIS2 and X-ray. They had a mean 2.3 (1-5) combined investigations allowing for 30 comparisons. The correlation between the two measurements was r =0.63 (p=0.0002). The Cobb angle measured on ISIS2 was less than that measured by radiograph in 27 out of 30 comparisons. The mean difference between the measurements was mean 6.4° with a standard deviation of 8.2° and 95% confidence interval of 3.3° to 9.4°.

In adolescent idiopathic scoliosis, curve severity and rib hump severity are related but measure different aspects of spinal deformity. As expected, these relate closely but not precisely. ISIS2 offers the promise of monitoring scoliosis precisely, without adverse effects from radiation. The small numbers in this series focus on the group of patients with mild to moderate curves at risk of progression. In this group, ISIS2 was able to identify curve stability or progression, without exposing the subjects to radiation.

Several surgical options have been utilised to treat patients with back dominant lumbar disc disease. The purpose of our study was to compare the outcomes in patients who underwent lumbar fusion with an expandable interbody device (B-TWIN) using different surgical techniques (PLIF, TLIF or posterolateral screws alone)

Observational study, retrospective analysis of prospectively collected data. Patients underwent a single level lumbar fusion. Group A: PLIF with B-Twin cage; Group B: TLIF with B-Twin cage and unilateral pedicle screw fixation and Group C: bilateral posterolateral screw fixation alone.

Functional outcomes were assessed using: SF-36, Oswestry Disability Index (ODI), Distress and Risk Assessment Method scores (DRAM) and the visual analogue pain scores (VAS).

There were 32 patients, 24 female and 8 male. Average age was 45 (range 33-63). Average follow up was12 months (range 2-36). Level of spinal fusion was 2 L3/4, 11 L4/5 and 13 L5/S1. Mean hospital stay was 5.8 days.

VAS improved in all 3 groups A 5.83 – 5; B 8 – 4.83; C 5.71 – 2.3.

ODI improved in all 3 groups A 0.5 – 0.35; B 0.51 – 0.44, C 0.42 – 0.16.

There was no statistical difference on comparison of the three groups.

There were no operative complications. One patient broke her interdody device during a all in the first post-operative week requiring a subsequent procedure.

Lumbar interbody fusions can safely be performed using an expandable interbody device. Good functional outcomes can be achieved in the majority of well selected patients

Pedicle screw constructs (PSC) in scoliosis are a recently established and widely accepted method of managing scoliotic curves posteriorly. There is a perceived improved coronal and rotational correction when compared to other posterior only constructs. With continued use of this method, the authors and deformity surgeons in general have become aware of persistent thoracic hypokyphosis.

This review of 3 years of scoliosis cases using PSC looks at four different implant strategies utilised to manage this problem and our current practice. These strategies were:

All titanium 5.5 mm rod diameter (Expedium, Depuy spine)

All titanium 5.5 mm rod diameter with periapical washers (Expedium, Depuy spine)

All titanium 6.0 mm rod diameter (Pangea, Synthes)

Titanium pedicle screws with 5.5 mm diameter cobalt chrome rods (Expedium Depuy spine)

We have reviewed our outcomes with these strategies with respect to thoracic hypokyphosis. Strategy 1 had the highest rate of hypokyphosis on postoperative radiographs. Strategy 4 seems to have the best correction of coronal and sagittal plane abnormality post operatively. As a consequence, our current practice is the use of titanium pedicle screws and 5.5 mm diameter cobalt chrome rods when managing scoliosis with a pedicle screw construct.

Generally, it is considered to be safe in preventing iatrogenic instability if half of the facet joint is left intact during decompression surgeries.

By removing half of the facets can we get adequate decompression of the nerve roots? Is there a difference at different levels in the lower lumbar spine? What is the inclination of the facet joint at each level and how does it affect the stability?

Retrospective study

We analysed 200 consecutive magnetic reasonance imaging (MRI) scans of the lumbosacral spine at L3/4, L4/5, and L5/S1 levels. We measured the difference in the distance from midline to the lateral border of the foramen and from midline to the middle of the facet joint at each level on either sides. The angle of the facet joint was also noted.

The distance to the foramen from the level of the middle of the facet joints seem to be between 5-6mm lateral at every level. The angle of the facet joints at L3/4 is 35.9°+/−7.4°, while at L4/5 it is 43.2°+/−8.0°, and at L5/S1 it is 49.4°+/−10.1°.

In lumbar spine decompression surgeries, after the midline decompression extending up to half of the facet joints, a further undercutting of the facet joints to 5-6mm is therefore required to completely decompress the nerve root in the foramen. The more coronal orientation of the facet joint at L5/S1 conforms better stability than that at L3/4level. Therefore, stabilisation of the spine should be considered if more than 2cm of the posterior elements are removed from midline at L3/4 level.

Thoracic spinal cord herniation is a relatively uncommon syndrome of anterior hemi cord dysfunction. However it has been reported in literature with increasing frequency over the last decade. Since the initial description of this clinical entity by Weitzman et al. in 1974, more than 100 cases have been described.

Although clinical features may vary considerably, as a clinical syndrome it is now widely recognized, and remains a potentially treatable cause of thoracic cord dysfunction.

Anterior spinal or thoracic cord herniation remains an uncommon yet a potentially treatable cause of thoracic myelopathy. Patients usually present in their middle ages, and literature suggests that there is a female predominance. The presenting symptom is usually a Brown Sequard syndrome, although other symptoms suggestive of thoracic cord dysfunction may be present. Although the symptoms are insidious the condition may lead to progressive paraparesis. The herniation is usually through a dural defect, the cause of which open to speculation. Operative treatment is advised, as the outcomes are generally favourable.

As part of a continued focus on this clinical syndrome we describe below a series of 4 patients with thoracic spinal cord hernias that presented to our neurosurgical service over the past 3 years and our experience in the treatment of this condition. Apart from one patient, in whom there possibly was an iatrogenic factor, the rest were all purely idiopathic. All the patients underwent surgical treatment and their outcomes were generally favorable.

We described a technique of measuring the flexibility of the rib prominence clinically before surgery, and aimed to analyse the results in patients with adolescent idiopathic scoliosis who underwent posterior correction with pedicle screw instrumentation.

This prospective study investigated the magnitude of rib humps before and after the operation when the patient was in Adam's forward bending posture. Also preoperatively, a flexion and derotation manoeuvre was performed and the corrected rib prominence was measured. This is compared to the magnitude of the rib hump present postoperatively at three months' follow up.

Seven consecutive patients with adolescent idiopathic scoliosis that underwent posterior surgical correction.

Clinical measurement of rib prominence using scoliometer.

The magnitude of the curve improved from a mean preoperative Cobb angle of 53.6+/−11.2° (range 45.3–72.5°) to a mean postoperative Cobb angle of 7.8+/−9.3° (range 0.4–17.6°). The mean preoperative magnitude of the rib hump was 12.3+/−6.9° (range 5-20°) which was then corrected to a mean magnitude of 1.3+/−2.2° (range 0-5°) by performing the above described flexion derotation manoeuvre. The mean postoperative magnitude of the rib hump was 3.0+/−3.1° (range 0-8°) with the patient in Adam's forward bend position. There was positive correlation between the postoperative residual rib hump and the reduced rib hump measured preoperatively using our described technique (r=0.8,p=0.05).

This flexion derotation test is a useful in assessing the amount of postoperative persistent rib hump after posterior correction of adolescent idiopathic scoliosis using pedicle screw instrumentation with derotation technique.

The footplate in the current available TDR is flat without any allowance for endplate concavity in the sagittal plane.

To assess the morphology of the endplates of the lower lumbosacral in the sagittal plane, and to identify the frequently occurring shape patterns of the end plates at each level.

Retrospective Study

200 consecutive magnetic reasonance imaging (MRI) scans of patients between the age of 30 and 60 years were analysed. In each endplate, the anteroposterior width, the height of concavity of the endplate, and the distance of the summit from the anterior vertebral body margin were noted. The shape of the endplate was noted as oblong (o) if the curve was uniform starting from the anterior margin and finishing at the posterior margin, eccentric (e) if the curve started after a flat portion at the anterior border and then curving backwards, and flat (f) if there is no curve in the sagittal plane.

The shape of the end plate is mostly oblong at L3 IEP(59%), equally distributed between oblong and eccentric at L4 SEP (o=43.5%, e=46.5%), eccentric at L4 IEP (e=62.5%), eccentric at L5 SEP (e = 59.0%), eccentric at L5 IEP (e=94.0%), and flat at S1 SEP (f=82.5%).

As there is a difference in the shape of the endplate at each level and they are not uniform, there is a need to focus on the sagittal shape of the footplate to avoid subsidence and mismatch of the footplate in cases of endplate concavity.

The purpose of this retrospective study, is to demonstrate the survivorship and clinical effectiveness of the Wallis implant, against low back pain and functional disability in patients with degenerative lumbar spine disease.

The Wallis Interspinous implant, was developed as a minimally invasive and anatomically conserving procedure, without recourse to rigid fusion procedures. The initial finite element analysis and cadaver biomechanical studies showed that the Wallis ligament improves stability in the degenerate lumbar motion segment. Unloading the disc and facet joints reduces intradiscal pressures at same and adjacent levels allowing for the potential of the disc to repair itself.

A total of 157 patients who had wallis ligament insertion between 2003 and 2009 were reviewed, with a mean age of 54 and were followed for 48 months on average.

Patients were assessed pre-operatively and post-operatively every 6 months by VAS pain score, Oswestry Disability Index and SF-36.

90% of patients improved, to show a minimal clinical difference, compared to the pre-operative evaluation. There is overall 75-80% good clinical outcome.

Low infection rate of 1.1%. Two cases of prolapsed discs at the same level requiring further discectomy, 7 required fusion. No fractures or expulsions.

The Wallis implant represents a safe non-fusion stabilisation device in the treatment of degenerative lumbar spine disease with canal stenosis. There is less soft tissue damage, quick rehabilitation, less morbidity and associated low complication rate.

Venous Thromboembolism (VTE) is the most common complication following major joint surgery. While attention has focused on VTE following joint arthroplasty their exists a gap in the literature examining the incidence of VTE in spinal surgery; with a shortage of epidemiological data, guidelines for optimal prophylaxis are limited.

This survey, undertaken at the 2009 BASS Annual Meeting, sought to examine prevailing trends in VTE thromboprophylaxis in spinal surgery and to compare selections made by Orthopaedic and Neurosurgeons.

We developed a questionnaire based around eight clinical scenarios. Participants were asked to supply details on their speciality (orthopaedics or neurosurgery) and level of training (grade) and to select which method(s) of thromboprophylaxis they would employ for each scenario. Thirty-nine participants provided responses to the eight scenarios; complete details, including speciality and grade of those surveyed, were complied for 27 of the 39 questionnaires completed.

LMWH was the preferred pharmacological method of thromboprophylaixs selected 31% and 72% of the time by orthopaedic and neurosurgeons respectively. For each of the eight clinical scenarios LMWH and BK TEDS were selected more frequently by neurosurgeons than orthopaedic surgeons who elected to employ early mobilisation and mechanical prophylaxis. Neurosurgeons were more likely to employ more than method of thromboprophylaxis.

Thromboprophylactic selections differed between the two groups; Neurosurgeons preferred LMWH and BK TEDS whilst Early Mobilisation and Mechanical prophylaxis were the preferred methods of thromboprophylaxis amongst orthopaedic surgeons. Based on the results of this survey neurosurgeons more closely adhered to guidelines outlined by NICE/BASS.

To investigate the clinical effectiveness and complications of caudal epidural steroid injections in the treatment of sciatica in patients with an MRI proven sacral tarlov cyst.

A Prospective case control study. All patients with corresponding radicular pain received a course of three caudal epidural steroid injections, two weeks apart and patients were reviewed at 3 months, 6 months and 1 year interval in a dedicated epidural follow up clinic. Data including demographics, MRI results, diagnosis and complications were documented. Outcome measures included the Oswestry Disability Questionnaire (ODQ), the visual analogue score (VAS) and the hospital anxiety and depression (HADS) score.

Overall patient satisfaction was recorded on a scale of 0-10.

38 patients with a sacral tarlov cyst were compared to a matched control group. In the sacral cyst group, mean VAS for axial pain reduced from 5.859 to 2.59 at three months (p<0.001). VAS for limb pain reduced from 6.23 to 2.53(<0.005). Mean ODI reduced from 45.49 at first visit to 21.98 at 3 months. Mean HADS also improved from 17 to 7. There was no statistical difference between the two groups. BMI did not affect the outcome in either group.

Based on our study, we conclude that presence of a sacral tarlov cyst is not a contraindication to caudal epidural steroid injection, as comparable significant improvement in both axial and limb pain in the short and intermediate periods was achieved without any major complications.

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.

To analyse the pain distribution in the acute and chronic phase following thoracolumbar fractures.

Prospective observational study

39 patients with fractures between T11 and L2, with no neurological deficit, were treated conservatively. Strict inclusion and exclusion criteria were applied. All had X-rays and MR imaging (whole spine) at post-injury and one-year follow-up.

The patients documented their pain distribution using pain drawing, along with 10 other domains of pain and functional outcomes for a period over 12 months. The pain distribution was analysed. The association of distal pain distribution to - other associated injury, resultant kyphosis, Pre-existing or increase in disc degeneration at the lower non-injured disc levels – were analysed and reviewed

The most common site of the pain distribution in both the acute (90%) and chronic phase (97%) was distal to the fracture (regions - iliac crest, lumbosacral junction and buttock). Factors mentioned above that could be related to distal pain distribution did not show any significant correlation (P>0.5) with different domains of pain outcome.

Some of the commonly believed reasons for distal pain distribution like resultant kyphosis and associated disc/facet pathologies were not supported by our study findings. The distal pain distribution corresponds to the scelerotomal referred pain mapping, which could be the probable explanation. Thoracolumbar pathologies could be the source of pain in patients complaining of low back symptoms. Distal pain distribution of spine pathologies should not be attributed as functional.

To describe a modification of the existing technique for C2 translaminar screw fixation that can be used for salvage in difficult cases.

Bilateral crossing C2 laminar screws have recently become popular as an alternative technique for C2 fixation. This technique is particularly useful in patients with anomalous anatomy, as a salvage technique where other modes of fixation have failed or as a primary procedure. However, reported disadvantages of this technique include breach of the dorsal lamina and spinal canal, early hardware failure and difficulty in bone graft placement due to the position of the polyaxial screw heads. To address some of these issues, a modified technique is described. In this technique, the upper part of the spinous process of C2 is removed and the entry point of the screw is in the base of this removed spinous process.

From October 2008 to March 2009, 6 patients underwent insertion of unilateral translaminar screws using our technique. The indications were: basilar invagination(three cases), C1/C2 fracture (two cases), tumour (one case). Age varied from 22 to 81 years (mean 48 years).

All patients had post-operative x-ray and CT scan to assess position of the screws. Mean follow-up was 6 months.

The screw position was satisfactory in all patients. There were no intraoperative or early postoperative complications.

Our modification enables placement of bone graft on the C2 lamina and is also less likely to cause inadvertent cortical breach. Because of these advantages, it is especially suitable for patients with advanced rheumatoid arthritis with destruction of the lateral masses of C2 or as part of a hybrid construct in patients with unilateral high riding vertebral artery. This technique is not suitable for bilateral translaminar screw placement.

Proponents of thoracoplasty suggest a better correction, obviating iliac crest donor site morbidity, obtaining bone grafts for fusion and better rib hump correction. Opponents suggest increase risk for chest complications, additional operating time and blood loss, and possible longer hospital stay. There are controversies in the literature about thoracoplasty and its effect on lung function changes. The aim of the study was to evaluate the effect and outcome of thoracoplasty in conjunction with pedicle screw construct in the treatment of thoracic adolescent idiopathic scoliosis on lung functions.

It is a retrospective study of consecutive series of 62 patients with thoracic adolescent idiopathic scoliosis surgically treated by single surgeon between 2007 and 2008 at a tertiary referral Orthopaedic Spinal unit. Posterior spinal fusion and thoracoplasty (n=32, all but one girls) were compared with 30 without thoracoplasty (all but one girls). Clinical and radiographic analysis was performed, including the SRS-30 questionnaire and Pulmonary Function Tests (PFT). Absolute and percent-predicted values of forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and total lung capacity (TLC) were evaluated preoperatively and at 3-months, 1 year and/or 2-year follow-up, and comparisons were made between two groups. The minimum follow-up was one year.

No statistical differences were found between the two groups in PFT's both pre-operatively and at latest follow up ranging 1 to 3 years. Our findings suggest that thoracoplasty did not adversely affected long-term PFT's in AIS patients compared to patients treated by posterior spinal fusion alone. Three-month postoperative pulmonary function test values in both groups experienced 15-30% decline which returned to the preoperative baseline at 1 year in > 90% patients. In thoracoplasty group, 5 to 8 ribs were resected and used for bone graft. Chest complications were observed in 2 patients requiring chest drainage. Prolonged donor site morbidity was noted in 3 patients.

Thoracoplasty showed comparable clinical and radiological correction without any significant pulmonary function compromise. Pulmonary function test values returned to the preoperative baseline at 1 year in > 90% patients.

There remains debate regarding which surgical approach gives the best outcome, anterior alone or posterior alone, in surgically relevant adolescent idiopathic scoliosis. The operation is mainly cosmetic in terms of health care advantage. This prospective study evaluated scar site preference and other relevant body image parameters prior to any intervention.

Patients and their parents had a structured interview involving SRS20 and Walter Reed Visual Assessment Scale as well as grading of nine AP and lateral clinical photographs specifically of anterior and posterior scoliosis surgery scars. Each clinical image was graded 1-10 on a scale of unsatisfactory and satisfactory. Parents completed assessments as well as the patients.

Results: 28 patients, 6 males, 22 females, 8 females were pre-menarche, mean age 14 (12-17), mean cobb angle 57, completed the study. Mean parental age 45.

There was no significant difference between mean scores for the four anterior scar (6.36) and the five posterior scar (6.35) images. p value 0.49. In parents the preferences were more apparent posterior 6.9, anterior 6.2 but this was not statistically significant (p=0.06)

There was no significant difference between all four domains of the SRS between parent and child. In terms of expressed preference the child had no preference in 7, thoracotomy in 7 and posterior midline in 14, whereas parents expressed no preference in 12, thoracotomy in 4 and posterior midline in 12.

In this prospective study there was no perceived difference in acceptability of anterior or posterior scars for scoliosis surgery approaches.

The study was designed to observe the patients emotional and physical response to total disc replacement surgery in the cervical spine.

A prospective cohort study of patients undergoing Cervical total disc replacement (TDR) surgery at our institution. Surgery was carried for radicular and or axial neck pain. The Activ-C TDR (Aesculap) was used. Pre and post operative data was collected using validated questionnaires.

13 Consecutive patients from Nov 2007 to Aug 2008 were studied. All patients were planned for surgical intervention for symptomatic degenerative cervical disc disease at single or multiple levels. 7 male, 6 female.

The Centre for Epidemiological Studies Depression Scale (CES-D) was used to assess the psychological impact. The Neck Disability Index (NDI) and a visual analogue scale (VAS) were used to assess the physical impact of the surgery.

NDI shows a significant improvement at 6 and 12 months (p= 0.002 and p=0.02 respectively). The VAS also shows significant improvement at 6 and 12 months (p=0.004 and 0.008 respectively) The CES-D improved but failed to show any significant improvement at either interval.

In our patient population surgical intervention with TDR for degenerative disc disease offers significant physical benefit over the short term. This does not correlate with an improvement in their emotional state.

Northumbria Healthcare NHS Trust, Ashington, UK

To assess if a pain diary is useful in assessment and management of patients who undergo diagnostic nerve root block (NRB) for lumbar radicular pain.

Prospective study

23 patients who underwent diagnostic NRB for lumbar radicular pain were given a pain diary. They recorded their response to one of four options from Day 0 to Day 14 (good relief, partial satisfactory, partial unsatisfactory, and no relief of leg pain) and could also add additional comments. A Consultant Spinal Surgeon reviewed the diary with the patient at 6-week follow up appointment to formulate a management plan.

Patient response, completion of the pain diary and final clinical outcome (surgical or non surgical treatment).

The response rate was 91% (21/23). The pain diary was very useful in 43% (9/21), useful in 33% (7/21) and not useful in 24% (5/21) of patients in formulating further management. There was a tendency for patients with complex problems and poor response to add descriptive notes and comments (9/ 23).

Patient compliance with pain diary was good and it has been valuable in making further management decisions. We found the pain diary to be a useful and inexpensive adjunct in the assessment of patients who underwent diagnostic NRB.

To determine if the use of high density implants (i.e. high proportion of pedicle screws relative to number of spinal levels involved) causes significant loss of thoracic kyphosis and its effect on sagittal balance in adolescent idiopathic scoliosis.

Retrospective analysis of pre and post-operative radiographs to assess sagittal balance and C7-L1 kyphosis angle.

17 patients (16 females, 1 male). All right sided single thoracic curves. All surgery performed by single surgeon (Senior author, ED)

Comparison of pre and post operative sagittal balance and C7-L1 kyphosis angle. Assessment of implant density (i.e. proportion of pedicle screw relative to number of spinal levels involved in correction).

9 patients demonstrated improved sagittal balance following surgery. There was no significant difference (p value 0.83) between the pre and post op C7-L1 kyphosis angle. Mean angle pre op 28.9 (95% CI 20.3 to 37.5). Mean angle post op 29.6 (95% CI 22.2 to 37.0). No correlation identified between sagittal balance correction and kyphosis angle. Metal density ranged from 79-100%.

Although the sample size in this series is modest, high density implants do not significantly affect the kyphosis angle in the operative management of adolescent idiopathic scoliosis in the thoracic spine.

The study is been conducted to compare the outcome of pedicle screw fixation in dorsolumbar fractures by long segment fixation and short segment fixation with a screw in fractured vertebra.

Study includes the consecutive patients of dorsolumbar fractures treated by either long segment or short segment fixation. Twenty patients were included in each category. Patients with or without neurological deficit were included. Patients with single fractured vertebra only were included.

Patients with single level dorsolumbar fracture were subjected to detailed radiological analysis preoperatively by measurement of height loss and kyphosis angle of fractured vertebra. Detailed neurological status was recorded. During the fixation the pedicle screw was inserted in less affected pedicle of fractured vertebra and decompression if needed was done by hemilaminectomy of other side. Bone graft

Postoperative kyphosis correction and restoration of height was calculated in both the groups. At 3 months, 12months and 24 months the maintenance of corrected kyphosis and restored height was recorded.

Neurological examination to record the effect of surgical intervention on neurological recovery was recorded at every examination.

All the patients had satisfactory outcome. The loss of correction in both the groups was comparable.

The treatment allows easier postoperative nursing and early mobilization of the patient. Segmental fixation with screws at the level of the fracture offers improved biomechanical stability. It allows additional fixation points that may aid in fracture reduction and kyphosis correction. It also reduces the duration of surgery, blood loss as well as cost of implant without significant compromise on outcome.

Pedicle screw at the level of fracture in short segment fixations provides added stability, better postoperative maintenance of corrected kyphosis at reduced cost of implant.

Purpose

To investigate the association between vertebral endplate signal changes (VESC) and low back pain (LBP).

Introduction

Osteoporotic fracture reduces vertebral stiffness, and alters spinal load-sharing. Vertebroplasty partially reverses these changes at the fractured level, but is suspected to increase deformations and stress at adjacent levels. We examined this possibility.

Background

Several theories have been put forward with respect to the mechanical role of the thoracolumbar fascia (TLF) but none have been substantiated in part due to an inability to explore its function in vivo. This study explored the use of ultrasound to image the layers of the TLF in vivo.

Purpose of study

A recent audit in our institution showed that 40% of Lumbar spine X-rays ordered by General Practitioners were outside the Royal College of Radiology guidelines. Little in 1998 had commented that GPs requested Lumber Spine X-rays for psychosocial reasons.

Background

The incidence of backpain is unknown in children because studies have been cross-sectional or longitudinal with few follow-ups of long intervals. Children cannot be expected to remember past events of backpain correctly. Therefore data-collection must be undertaken with short intervals and using other methods than questionnaires only.

Staying active, including walking is promoted as being beneficial for patients with low back pain (LBP). The abdominal muscles appear to influence the stability of the spine and their activity has been shown to change when patients have LBP. Walking with Nordic walking poles has been shown to influence forces on the lower limbs, but little research has investigated the effect on the trunk muscles. Aim: to study the effect of walking using Nordic walking poles on abdominal muscle activity and lower limb forces.

Method 15 healthy subjects gave informed consent (5 males. 10 females, age 21.06 yrs.(±88), height 174.45cms (±11.1), weight 71.44 kg (±15.2)). Following a period of walking training with Nordic walking poles data was obtained during a period of walking for internal IO) and external oblique (EO) using surface electromyography activity and vertical lower limb forces (Newtons, (N)) with (WP) and without Nordic walking poles (NP). SEMG data was normalised to maximum voluntary contraction.

Purpose

To compare the effectiveness of the McKenzie method and spinal manipulation when used adjunctive to information and advice for patients with clinical signs suggestive of disc-related symptoms for duration of more than 6 Weeks.

The Royal Liverpool and Broadgreen University Hospital, Liverpool, UK

Plasmacytoma is the localised form of multiple myeloma, which can affect any part of the body including the axial skeleton (Kelly et al, 2006; Ampil et al, 1995). These myelomas/plasmacytomas arise from one malignant clone of cells, which secrete the same type of immunoglobulin. Where the clone of cells remains localised, it is known as plasmacytoma, but when there is spread of the malignancy to multiple bones and marrow, it is known as multiple myeloma (Boccadoro and Pileri, 1995).

We present a case of solitary sacral bone plasmacytoma (SBP), in a seventy year old man which presented as low back pain, following a fall. He was neurologically intact, and had no sphincteric incontinence, but MRI revealed a large expansile lesion in S1, which caused severe spinal stenosis, involving the left L5 exiting foramen, with an irregular area of low signal posteriorly. Bone scan showed increased tracer uptake in L5 and a mixed hot/photopaenic appearance in the mid-sacral region indicating tumor involvement. Myeloma screen confirmed that the serum IgA was high, with positive kappa monoclonal band, positive Bence Jones Protein (BJP), normal IgM and IgG, and normal calcium profile. CT-guided biopsy revealed sheets of mature plasma cells, consistent with the diagnosis. Fine needle aspiration biopsy of an enlarged groin lymph node revealed neoplastic infiltration, consistent with myeloma. Skeletal survey and CT chest/abdomen/pelvis (CAP) were not contributory. The patient had six courses of radiotherapy and improved remarkably, and is being considered for chemotherapy as well as follow up in the out-patients' department.

Purpose and background

Research on people's own experiences of living with sciatica is limited and this study aims to contribute to a better understanding of the impact of sciatica and its treatment.

Purpose of study

NICE recommends 8-9 sessions of non operative therapy for back pain that has lasted for 6 weeks but less than 12 months. NICE recommended exercises, manual therapy, acupuncture and suggested that Lumbar supports, TENS, Ultrasound and Traction should not be offered. Since multiple methods and disciplines were available a survey was conducted among the local General Practitioners to determine what non operative methods they preferred and how it matched with NICE's recommendation.

Background and purpose

The musculoskeletal system is a common, but often overlooked, cause of chest pain. Little is known about the efficacy of spinal manipulation for this condition. The purpose of the present study is to evaluate the relative effectiveness of two conservative treatment approaches for acute musculoskeletal chest pain, 1) a spinal manipulation-based therapy as a typical example of chiropractic treatment and 2) self-management as an example of minimal intervention.

Purpose of study and background

This study aimed to investigate if the PD-Q classification was predictive of outcomes at 3 and 12-months follow-up in LBP patients with associated leg pain.

Identification of clinically important subgroups and targeted treatment is believed to be important in low back pain (LBP) care. The PainDETECT Questionnaire (PD-Q) is designed to classify whether a person has neuropathic pain, based on their self-reported pain characteristics. However, it is unknown whether this classification is a prognostic factor and/or predicts treatment response.

Purposes of the study and background

MRI of the lumbar spine is a clinically important examination in low back pain (LBP) when serious underlying pathology or radiculopathy is suspected or when pain does not improve, e.g. to identify herniated discs. The general population has high confidence in this modality. Little documented knowledge exists about how the MRI results should be communicated to the patients in an optimal way. The aim of this study was to explore the patients' perspectives, i.e. worries, thoughts and interpretations of terms used when health care providers convey the MRI results.

Purpose

Health literacy, the ability to seek, understand and utilise health information, is important for health and health-related decisions. Suboptimal health literacy is associated with poorer health outcomes in many chronic conditions although this has not been studied in chronic low back pain (CLBP). This study explored health literacy in a community cohort with and without CLBP.

Introduction

Vertebral osteoporotic fracture increases both elastic and time-dependent (‘creep’) deformations of the fractured vertebral body during subsequent loading. This is especially marked in central and anterior regions of the vertebral body, and could explain the development of kyphotic deformity in life. We hypothesise that vertebroplasty can reduce these creep deformations.

Purpose and background

Although low back pain (LBP) with leg pain, is considered by most a poor prognostic indicator, it is at the same time believed to have a favourable natural resolution, and is often treated along similar lines to non-specific LBP, in line with current guidelines. It is unclear whether patients with LBP and leg pain are a distinct subgroup that might benefit from early identification and targeted interventions. We set out to investigate the impact of LBP with leg pain on health outcomes and health resources compared with that of LBP alone, and to explore which factors contribute to the observed disability outcomes.

Aims/background

Current treatment recommendations advocate various exercise modalities for people with chronic Low Back Pain (cLBP)1. Walking appears to represent an inexpensive and readily accessible activity for a range of individuals, including those who were previously sedentary. However, the effectiveness of such interventions are uncertain in cLBP.

Background and purpose

Sleep disturbance is frequently reported by people with chronic low back pain (CLBP >12 weeks), but there is limited knowledge of their sleep quality compared to healthy people. While disturbed sleep influences patients' mood, quality of life and recovery, few studies have comprehensively investigated sleep in CLBP. This study investigated differences in sleep profiles of people with CLBP, compared to age- and gender matched controls over seven consecutive nights.

Background

It is generally acknowledged that low back pain (LBP) is a common condition already in childhood. However, not many studies have looked at the way LBP tracks over age and how common it is until early adulthood.

Purpose

To compare the contribution of physical, psychological and social indicators to predicting disability after one year between consulters with low back pain (LBP) of less than 3 months duration and more than 3 months duration.

Purpose of study

The Royal College of Radiology (RCR) provides guideline criteria to order lumbar spine X-rays for back pain. An audit was undertaken in our hospital to see compliance with this guideline.

A clinical diagnosis of Myofascial Pain Syndrome (MPS) requires manual palpation for the identification of at least one clinically relevant trigger point (TP). However, few comparable, high quality studies exist regarding the robustness of TP examination. Our aim was to determine the inter-observer agreement of TP examination among four examiners and whether reproducibility is influenced by examiner clinical experience. Two experienced and two inexperienced clinicians each performed a standardized palpation of the upper Trapezius musculature. Each observer was asked to judge the presents/absence of clinically relevant TP(s) using clinician global assessment (GA). A random case mix of 81 female participants was examined, 14 being asymptomatic and the remainder suffering from neck/shoulder pain. Examiners received psychomotor training and video analysis feedback provided prior to and during the study in order to improve protocol standardization. Kappa co-efficients were calculated for all possible examiner pairings. Good agreement was noted between the experienced pairing (κ= 0.63). Moderate levels of agreement were observed among the two mixed pairings (κ=0.35 and 0.47 respectively). However, poor agreement was observed for the inexperienced pairing (κ=0.22). Inter-observer agreement was not stable with the experienced pairing in particular, exhibiting a sharp decline in agreement during the latter portion of the study. Identification of clinically relevant TPs of the upper Trapezius musculature is a reproducible procedure when performed by two experienced clinicians. However, an experienced-inexperienced observer pairing can yield acceptable levels of agreement. A protracted period of data collection may be detrimental to inter-observer agreement.

Introduction

It has previously been reported ^(1,2,3) that EMG signals from the lumbar spine are highly prone to contamination by ECG artefacts. It has also been reported that Independent Component Analysis is a suitable method for extracting this contamination (4).

Background and purpose

Trajectories of change over time can illustrate the course of pain. Back pain trajectories have previously been identified among adults. Understanding different patterns of back pain among adolescents could shed light on how persistent back pain develops. We aimed to identify and compare trajectories of back pain among adolescents in the general population.

Background

The outcome of studies on back pain is usually measured at specific intervals (1 month, 3 months, etc.) However, because LBP is a recurring condition it would be more relevant to identify outcome in relation to course over time. A new data collection tool was recently developed (SMS-Track), allowing this to be done.

Background

Exercise can be effective in treating Chronic Low Back Pain (CLBP) (Hayden et al 2005). Pilates-based group exercise programmes may be useful in the treatment of CLBP.

Purpose

This pilot study tested the feasibility of a self-determination theory-based communication skills training programme designed to increase physiotherapists' psychological needs supportive behaviour when treating patients with chronic low back pain (CLBP>12 weeks).

Advisors

PhD J Hartvigsen, PhD P Aagaard, University of Southern Denmark. PhD G Br⊘nfort, Northwestern Health Sciences University, Minneapolis, MN, USA and NIKKB. PhD G Kawchuk, Canada Research Chair in Spinal Function, University of Edmonton, Alberta, Canada. PhD A Breen, Institute for muscoloskeletal research & clinical implementation, Bournemouth, England. PhD J Rasmussen, Institut for Maskinteknik og Anybody Group, Aalborg Universitet

Background and purpose

Sleep disturbance is a prevalent symptom in people with chronic low back pain (CLBP >12 weeks), but there is currently no knowledge of the effectiveness of physiotherapy for this problem. This study evaluated the feasibility of a randomised controlled trial (RCT) exploring the effects of physiotherapy on sleep disturbance in CLBP [Current controlled trial ISRCTN 54009836].

The difficulties in the management of chronic lower back pain are recognised by professionals and patients alike but this recognition can stem from very different perspectives. This paper discusses how patients identify ways in which their experience and perception of pain changes over time and how that impacts on their relationship with professionals delivering a treatment regime. It presents the results of secondary analysis of longitudinal patient data collected under a serial qualitative interview methodology in which the analytical focus is on patients' changing expectations and perceptions of pain. This orientation to the data demonstrates not only established notions of ‘acceptance’ within biographical disruption, but also ways in which individuals revise, mediate, negotiate and integrate meanings of pain to gain both short and long-term coherence. By taking a more holistic view of patient narratives that situates treatment prescriptions and related behaviours within the context of individuals' everyday life, the analysis highlights ‘sense-making’ as a dynamic process. In doing so, it shows that patients draw reference points not only from their most immediate experiences of chronic low back pain but also from the (dis)continuities of lifecourse experience prior to the onset of pain and anticipated for the future. The paper therefore seeks to both illuminate the dynamics of the patient perspective and provide indicators of where some differences in patient/professional perceptions may lie. Suggestions for promoting concordance between patients and health care professionals will be discussed.

Background

Fissures in the anulus fibrosus are common in disc degeneration, and are associated with discogenic pain. We hypothesise that anulus fissures are conducive to the ingrowth of blood vessels and nerves.

Background

There is concern that a sedentary lifestyle in childhood is harmful to spinal health. The literature stands divided, as there are reports also of an increased injury rate in children who are physically active. Children cannot be expected to remember correctly amount of physical activity in the past nor can they remember correctly past events of backpain. We therefore used a new method, SMS-Track, to collect weekly data over a long period of time.