Introduction: Restoration of vertebral height for burst fractures can be achieved either anteriorly, posteriorly or combined.

Aim: To biomechanically assess and compare stiffness of 1) posterior pedicle screws with Synex, 2) Synex+ Double screw+rod Ventrofix 3) Synex+ Double screw+ Single rod and 4) Synex+ Single screw+ Single rod in reconstructing an unstable burst fracture following anterior corpectomy.

Method: Fresh frozen calf lumbar spines (L3–L5) were dissected and L4 corpectomy performed. L3 and L5 were mounted on a plate and fixed. Loads were applied as a dead weight of 2Nm. The range of movement was measured using the Qualisys motion analysis system using external marker clusters attached to L3 and L5. Bony landmarks were identified with marker clusters as baseline. The movement was measured between the 2 marker clusters.

Five specimens were implanted for each group 1) with pedicle screw (into L3 and L5) and tested with/without Synex (expandable) cage anteriorly, 2) implanted with a Synex cage and Double screw+rod Ventrofix system, 3) Synex cage and Double screw+ Single rod Ventrofix construct and 4) Synex cage and Single screw+ Single rod Ventrofix system.

Results: Reconstruction of the anterior column with the combination of Synex and double rod Ventrofix produces a stiffer construct than the pedicle screw system in all planes of movement (p= 0.001 in rotation).

The double screw/ single rod system is less effective than the Ventrofix System but is comparable to the pedicle screw construct.

The single screw/ single rod construct leads to unacceptable movement about the axis of the inferior screw particularly in extension with a ROM much greater than the intact spine (p< 0.001)

Conclusion: Thus biomechanically we recommend Synex and double rod Ventrofix construct to reconstruct the anterior vertebral column following corpectomy for unstable burst fractures.

Aim: To determine the incidence of adjacent level osteophytes in patients who have had anterior cervical fusion using an anterior cervical plate as compared to those who are fused without an anterior cervical plate.

Design: We retrospectively reviewed the lateral radiograms of sixty two patients who have had an anterior cervical fusion with a minimum follow up of twelve months.

Materials and methods: We looked for the development of adjacent level osteophytes in these patients at their final follow up, which was generally at the time radiological fusion. There were 27 patients in the first group who had an anterior cervical plate used to fix the vertebrae in addition to the Cervios cage, while the 35 patients in the second group in whom only a Rabea cage was used for the fusion. The mean follow-up was 20.6 months (range 12–48).

Results: 64.3% of the patients who had an anterior cervical plate developed adjacent level osteophytes while none of the patients who have had the fusion without the cage developed the osteophytes.

Conclusion: We found the patients who had an anterior cervical interbody fusion using a plate had a significant risk of developing adjacent level osteophytes while this is not seen in patients who do not have the plate for the fixation.

Objective: To investigate the clinical outcomes, and the requirement of surgery following selective nerve root block performed for cervical radicular pain in patients with MRI proven disc pathology.

Methods: Thirty consecutive patients with cervical radiculopathy and correlating MRI pathology were studied. Mean age of patient was 46yrs (range 28–64yrs). Twenty nine of the thirty patients also complained of associated neck pain. All underwent fluoroscopically guided, selective cervical nerve root block with steroid (20mg Depomedrone) and local anaesthetic (0.5ml Bupivo-caine 0.25%). Radiographic contrast was used to confirm needle position. All procedures were conducted by the same clinician.

Pre and post procedure pain and physical function scores were noted using the standard SF 36 questionnaire, as well as whether subsequent surgery was required. Mean follow up time was seven months (range 2–13 months).

Results: 81% of patients reported an improvement in arm pain, and 66% in neck pain following the procedure. 77% of patients had an improvement in pain score (mean improvement 16 points). 68% of patients had an improvement in physical function score (mean improvement 20 points). At the time of follow up only one patient had undergone surgery for cervical radicular pain.

Conclusion: This study suggests that fluoroscopically guided selective nerve root block is a clinically effective interventional procedure in the management of cervical radicular pain, and may prevent the need for open surgery.

Patients admitted to trauma wards are routinely screened for MRSA pre-operatively. The majority of them have implant surgery before the screening results were available. The aim of our study was to identify the incidence of MRSA wound infection in these patients and their outcome following it.

We randomly reviewed 40 patients who were colonised with MRSA pre-operatively and have had implant surgeries. The case notes, drug charts and the microbiology were reviewed to identify the incidence of MRSA wound infection and its outcome in these patients. The place of residence, site of colonisation and the treatment given were also considered.

70% of the patients were admitted from home and 20% had previous admission within one year. The commonest site colonised is the nose (50%) followed by the perineum in 20%. Multiple sites were colonised in 10% of the patients. Only 50% of them with positive nasal MRSA were given nasal bactroban and chlohexidine wash was given in only 70% of them with MRSA colonisation in other areas. 22.5% (9/40) of the patients developed MRSA infection post operatively and they were treated with vancomycin or teicoplanin. Wound debridement and washout were done in 67.5%. 75% of the MRSA infected wound healed well with no MRSA in the wound site after treatment. 25% of the MRSA infected wounds had persistent MRSA in the wound.

As per our study the incidence of MRSA wound infection in patients colonised pre-operatively is about 22.5%. Most cases seem to heal well without much complication with appropriate antibiotics and wound care.

Background: More patients are turning to the Internet for health-related information. Studies indicate that this information is being used to make decisions about their management. The aim of this study was to assess the information available specific to scoliosis on the Web using four common search engines.

Methods: Four search engines (Google, Yahoo, Hotmail and Ask Jeeves) were used in scanning the Web for the following key word- “Scoliosis”. Both U.K. only and World Wide sites were accessed. Four Spinal Surgery Consultants independently graded each site for layout, content, relevance to patients as opposed to medical professionals, ease of use and links to other sites. Each point was marked on a scale of 0–2 and a total of 10 points available. Web sites were assessed via U.K. search engines and forty via World Wide search engines. Good was awarded to a site with a score of 7–10; an average awarded for a score of 4–7 and poor was given to a site with a score of 0–4.

Results: For the U.K. search engines, twenty sites were evaluated and five common sites identified (spineuniverse.com, S.A.U.K.org, orthoteers.co.uk, B.O.A.ac. uk and scoilosis.info). From these sites only two were given a rating of good. For the World Wide Web search engines eighteen sites evaluated and seven common sites identified (SRS, spineuniverse.com, scoliosis.org, orthinfo.aaos.org, iscoliosis.com, scoliosisrx.com and scoliosis-world.com). From these sites four were given a rating of good. It was evident that the Scoliosis Association of United Kingdom did not appear in three of the search engines but only in Hotmail.

Conclusion: These results suggest that there are good sites available for patients to access information with regards to their condition and treatment options but there are also very poor sites available where incorrect information is available. Commonly, unfamiliar users of the Web will not search U.K. sites specifically and could easily miss the S.A.U.K. site, which is an excellent site and was one of the two sites via the U.K. search engine awarded a good score. Obviously, there were more good sites via the World Wide Web due to the American healthcare system. We recommend that leaflets should be available to parents and patients with scoliosis with information from the BSS of the condition and available Web sites with good ratings. Also we recommend that these sites be linked to the Royal College of General Practitioners Web site to provide reference on good practice.

Background: Although either anterior or posterior corrective scoliosis surgery has been reported in Jehovah’s Witnesses, we did not find any reports of single stage combined anterior and posterior scoliosis surgery being done in these patients. We report our experience in one such case.

Methods: This is a case report of a 14 year old female Jehovah’s Witness who had cerebral palsy with total body involvement presented with right sided thoracolumbar scoliosis. She was wheel chair bound and was being treated in a spinal brace. She had a partially correctible thoracolumbar curve from T5 to L2 measuring 94°, which reduced to 74° in brace. Her parents were counselled regarding scoliosis surgery. They consented for the surgery and also signed a special consent form for Jehovah’s witnesses specifying that they would prefer their child not to have transfusion of blood or blood products under any circumstances. They were explained that in case of excessive bleeding, further surgery may need to be deferred.

Results: Although her pre-op Haemoglobin was 14.3 g/dl, she was given oral ferrous sulphate because of low serum ferritin level (34 mcg/L). After induction of anaesthesia, intra operative hemodilution was performed using 900 ml of crystalloid. During surgery aprotinin infusion was used with controlled hypotension and cell salvage. Anterior release was performed followed by posterior instrumentation. The operation lasted for 8 hours. Central venous pressure and arterial oxygen saturation remained stable throughout the operation. She recovered well following surgery, with post-operative haemoglobin of 9.8 g/dl and was discharged on the7th post-operative day. Oral iron supplementation has been continued after surgery.

Conclusion: Due to religious reasons, Jehovah’s Witnesses do not accept transfusion of blood and blood products, which makes major surgery like scoliosis correction difficult as it involves a significant amount of blood loss. Such patients benefit from pre-operative iron supplementation, pre-operative haemodilution, intraoperative hemodilution, cell salvage, use of Factor 7, aprotinin and erythropoietin. These modalities have made it possible to perform major operations like scoliosis surgery in this group of patients.

Introduction Local steroid injection is commonly performed as a treatment for facet joint arthritis in the lumbosacral spine. The injection is performed under image guidance for which some surgeons utilise antero-posterior (A-P) imaging only while others prefer oblique imaging.

Purpose The aim of this study is to find out the difference in the functional outcome in patients who received the facet joint steroid injection by A-P imaging and those who had the injection by oblique imaging.

Material and Methods A prospective randomised controlled trial was performed by randomly allocating the 20 patients who were diagnosed to have facet joint arthritis clinically and by magnetic reasonance image scans, and who were then placed in the list for facet joint injections. Ten patients in Group I received the facet joint injections with A-P imaging while 10 patients in Group II received the facet joint injections with oblique imaging using image intensifier. All the patients received 40mg of methylprednisolone acetate with 1mL of 1% lignocaine and 1mL of 0.5% bupivacaine to each joint. The duration of the entire procedure was noted. Short Form-36 (SF-36) questionnaire was used before the procedure and at six weeks after the procedure to assess the functional outcome.

Results All the patients were followed up for a period of six weeks. The mean age was 51.3 yrs in Group I and 48.3 yrs in Group II. The male to female ratio was 3:7 in Group I and 2:5 in Group II. One patient in Group I had the facet injections at only one level while it was in two patients in Group II (L4/5 or L5/S1). Further one patient in Group I and one in Group two had unilateral facet joint injections at two levels. All the other patients had bilateral facet joint injections at two levels (L4/5 and L5/S1). One patient was excluded from the study as the A-P image obtained was very poor and that an oblique image had to be performed to visualise the facet joint because of obesity. The mean duration of the procedure was 18.33 min (10–25 min) in Group I and 22 min (10–35 min) in Group II (p=0.14, 95%CI −8.5 to +1.4). The patient function score improved from a mean of 20.0% to 32.5% after the injection in Group I, and from 30.0% to 41.0% in Group II. The pain score improved from a mean of 33.3% to 47.2% in Group I, and from 35.6% to 44.4% in Group II. The difference in physical function score (p=0.85, 95% C.I. −15.29 to +18.29), and pain score(p=0.71, 95% C.I. −24.21 to +34.22) between the two groups were not statistically significant.

Conclusions There is no difference in the functional outcome of patients treated by facet joint injections using A-P or oblique imaging. There is no significant difference in the duration of the procedure as well between the two techniques. However, with experience we found that it may be difficult to visualise the facet joint clearly by A-P imaging alone in obese individuals.

Background: Campbell et al from Texas have pioneered the use of Vertical Expandable Prosthetic Titanium Rib (VEPTR) in congenital scoliosis. Our centre is the first in the UK to use it and we report our experience of 5 cases done in the past 2 years. VEPTR works on the principle of expansion thoracoplasty and thoracic spinal growth of upto 0.8 cms/year has been reported by the developers of this device.

Methods: This case series includes one child who had the index surgery in America and is undergoing sequential expansion in Cardiff. All surgeries were done using a standard technique with monitoring of somatosensory evoked potentials. After appropriate soft tissue and bony releases, VEPTR was inserted and expanded by 0.5 cms to maintain tissue tension. Subsequent expansions were done as day case surgeries at 4–6 month intervals through a small incision over the VEPTR. We assessed clinical and radiographic assessment, which included – hemithorax height ratio, Cobb angle, interpedicular line ratio, space available for the lung.

Results: There were 3 males and 2 females with mean age of 6.3 years (range 0.9 to 9 years) at the time of index operation. Average follow up is 2 years (0.4 to 5 years). Average hospital stay for the index surgery was 5 days (4–7 days). All patients had mean of 3 expansions (range: 0–6). Mean improvement in the Cobb angle was seen from 48° to 36° at last followup. Space available for lung improved from a mean of 72 % to 86 %. Mean improvement in hemithorax height ratio was from 72.5% to 86%. One child had mild pain due to prominent metalwork; 2 children had transient brachial plexus neurapraxia, one of whom had progression of a secondary cervical curve and is awaiting further surgery for the same.

Conclusion: Our early results show good improvement of clinical and radiographic parameters. Transient nerve palsies have been well reported on the concave side and occur due to traction on the nerves as a result of increased height of the thoracic cage. This occurred in one initial case and has not been seen later. These results are encouraging but do indicate a learning curve.

Background: Long waiting lists in the NHS are a cause for public concern especially with regards to progressive conditions like scoliosis. We reviewed records to 61 patients to ascertain whether waiting time had any detrimental influence on their surgical management.

Methods: Retrospective review. Assessment of clinical records and radiographs of 61 patients who had scoliosis surgery over past two years was done by two independent investigators. Patient demographics, waiting times between referral and outpatient review and waiting time for surgery were collected.

Results: There were 41 females and 20 males with mean age of 11.8 years (range, 1– 22 years). Thirty-four patients had thoracic curves (28- right sided), 21 had thoracolumbar curves (19- right sided) and 6 patients had right sided lumbar curves. Mean Cobb angle at presentation was 58° (range,17°–90°) which increased to 71°(range, 30°–120°) at surgery. Average waiting time to be seen in the clinic was 16 months. Average waiting time for surgery was 10 months. Rapid curve progression was seen in twelve patients (20%), of which 10 required more extensive surgery than originally planned. Their mean Cobb angle at presentation was 48° (range, 45°– 80°), which increased to a mean of 59° at surgery (range, 50°–92°). At presentation their Risser grades were: 5 – grade 0, 3- grade 2, 2- grade 4. These 10 patients had waited averagely 7.8 months to be seen in the clinic and for 11 months to have the surgery.

Conclusion: Significant curve progression occurred in 20 % of patients waiting to have scoliosis surgery. Ten of those required much more extensive surgery than originally planned. Long waiting times therefore have a detrimental effect on the surgical management of scoliosis patients.

Background: There has been an exponential rise in Internet use over recent years with over 11 million homes in the United Kingdom currently having access to the Internet. Previous studies have shown that up to 50% of orthopaedic outpatients have researched their condition on the Internet and that this percentage is dependent upon the condition from which they are suffering. The aim of our study was therefore to assess the prevalence of Internet usage among three groups of orthopaedic outpatients and to further determine how the patients felt their Internet research compared to the information received at consultation.

Methods: Data was collected from 150 patients / parents attending three outpatient clinics; 50 consecutive patients attending scoliosis clinic; 50 patients attending paediatric orthopaedic clinic; 50 patients attending back pain clinic.

Results: 58% of scoliosis, 22% of general paediatric and 30% of back pain patients had researched their condition on the Internet. 83% of scoliosis, 64% of paediatric and 80% of back pain patients found this information useful. Nearly all patients, however, would trust their doctor more than the Internet.

Conclusion: We believe therefore that clinicians need to keep up to date with information available on the Inter-net and provide recommended websites to patients wishing to consolidate their knowledge of their condition.

Introduction Local steroid injection is commonly performed as a treatment for facet joint arthritis in the lumbosacral spine. The injection is performed under image guidance for which some surgeons utilise antero-posterior (A-P) imaging only while others prefer oblique imaging. The entry point and the direction of the needle entering into the facet joint are different in these techniques. Further the difficulties encountered in both the techniques are different.

Purpose To find out the difference in the functional outcome in patients who received the facet joint steroid injection by A-P imaging and those who had the injection by oblique imaging.

Material and Methods A prospective randomised controlled trial was performed by randomly allocating the 20 patients who was diagnosed to have facet joint arthritis clinically and by magnetic reasonance image scans, and who were then placed in the list for facet joint injections. Ten patients in Group I received the facet joint injections with A-P imaging while 10 patients in Group II received the facet joint injections with oblique imaging using image intensifier. All the patients received 40mg of methylprednisolone acetate with 1mL of 1% lignocaine and 1mL of 0.5% bupivacaine to each joint. The duration of the entire procedure was noted. Short Form-36 (SF-36) questionnaire was used before the procedure and at six weeks after the procedure to assess the functional outcome.

Results All the patients were followed up for a period of six weeks. The mean age was 51.3 yrs in Group I and 48.3 yrs in Group II. The male to female ratio was 3:7 in Group I and 2:5 in Group II. One patient in Group I had the facet injections at only one level (L4/5 or L5/S1) while it was in two patients in Group II. Further one patient in Group I and one in Group two had unilateral facet joint injections at two levels. All the other patients had bilateral facet joint injections at two levels (L4/5 and L5/S1). One patient was excluded from the study as the A-P image obtained was very poor and that an oblique image had to be performed to visualise the facet joint because of obesity. The mean duration of the procedure was 18.33 min (10–25 min) in Group I and 22 min (10–35 min) in Group II (p=0.14, 95%CI −8.5 to +1.4). The patient function score improved from a mean of 20.0% to 32.5% after the injection in Group I, and from 30.0% to 41.0% in Group II. The pain score improved from a mean of 33.3% to 47.2% in Group I, and from 35.6% to 44.4% in Group II. The difference in physical function score (p=0.85, 95% C.I. −15.29 to +18.29), and pain score (p=0.71, 95% C.I. −24.21 to +34.22) between the two groups were not statistically significant.

Conclusions There is no difference in the functional outcome of patients treated by facet joint injections using A-P or oblique imaging. However, with experience we found that it may be difficult to visualise the facet joint clearly by A-P imaging alone in obese individuals.

Background: Type II odontoid fractures are the commonest upper cervical spine injury in the elderly, following minor falls. Structural heterogeneity within the axis with deficiency of bone mass in the base of the odontoid process has been attributed for these fractures.

Aims: To analyse whether osteoporosis at the dens-body junction is directly related to the occurrence of odontoid fractures in the elderly.

Material and Methods: We studied the reformatted CT scan images of 36 patients over the age of 70 years who had cervical spine injuries following minor trauma. In all these patients the severity of osteoporosis at the dens-body junction, and in the peg and body of axis were evaluated. The severity was graded into none, mild, moderate and severe, depending on the cortical thickness, trabecular pattern, and the size of holes (absence of trabeculae) using sagittal, coronal and transverse sections of CT scan pictures. The osteoporosis was graded into none, mild, moderate and severe. Statistical analysis was performed using Pearsons Chi-square test to find the significance of osteoporosis at the dens-body junction in producing Type II odontoid fractures in the elderly.

Results: Type II odontoid fractures was seen in 21 patients. Eleven of the 21 patients with Type II fractures and eight of the 15 patients with no Type II odontoid fractures had significant osteoporosis at the dens-body junction. Five patients with Type II fracture and eight patients with no Type II fractures had significant osteoporosis at the dens and body of axis. Statistical analysis showed that the osteoporosis at the dens-body junction was not significant in patients with Type II odontoid fracture compared to those with no Type II odontoid fracture (Chi-square value = 1.1; df = 3, p = 0.78).

Conclusions: Eventhough osteoporosis is one of the factors that increase the incidence of Type II fractures of the odontoid process in the elderly, it is not a direct aetiological factor.

Study Design: Retrospective Series.

Objectives: To analyse loss of correction of the anterior wedge angle and the components responsible for the recurrence of kyphosis after surgical stabilisation of dorsolumbar fractures, and to assess the return of functional capacity in these patients.

Materials and Methods: Between January 1998 and March 2003, 34 patients had posterior stabilisation performed with the Universal Spine System (Synthes) for dorsolumbar fracture at a single level with no neurological deficit. There were 26 AO Type A fractures, 5 Type B fractures, and 3 Type C fractures. Serial standing lateral radiographs were taken from the immediate postoperative period to the most recent follow-up. The anterior wedge angle, the heights of the discs above and below the fractured vertebra, and the heights of the vertebral bodies above, at, and below the fractured level were measured. The height at each level was measured in three segments (anterior, middle and posterior). The values were normalised to avoid discrepancies while comparing radiographs. The difference in the height of each segment measured between the immediate postoperative period and the most recent follow-up were computed. Short Form 36 (SF-36) was used to assess the functional outcome in each.

Results: The mean follow-up period was 23.6 months (9 to 48 months). The mean anterior wedge angle was 10.1 ± 7.2 degrees in the immediate postoperative period and 17.1 ± 10.9 degrees at latest follow-up (p< 0.001). The mean loss of correction was 7.0 ± 8.5 degrees (−11 to 24) and this showed a linear relationship to the preoperative anterior wedge angle. Furthermore there was a linear increase in the loss of correction of the angle as the follow-up period increased. The correlation between the corresponding difference in the height of each segment and the degree of loss of correction of the anterior wedge angle showed significant correlation to the decrease in the anterior segment height at the fractured vertebral body level (Pearson’s coefficient r=0.53 significant at 0.01 level, p=0.001). The mean physical function score from SF-36 was 56.3 and the mean bodily pain score was 49.7. There was no relationship to the angle of kyphosis at follow-up to the physical function score (r=0.12, p=0.50) and the bodily pain score (r=0.14, p=0.44).

Conclusions: There is a progressive loss of correction (increasing kyphosis) after posterior stabilisation with instrumentation that roughly approximates the initial decrease in anterior height of the fractured vertebral body. The degree of loss of correction does not depend on the type of fracture. The loss of correction is related to the preoperative angle of kyphosis.

Study Design: Retrospective review.

Objectives: Rugby union has recently become a highly-paid professional sport. Players requiring anterior cervical discectomy wish to know the effect this will have on their career. To answer this question, the result of the above procedure in professional rugby players was studied.

Methods: A retrospective notes review and telephone interview were conducted on 19 professional rugby players who had a cervical discectomy between 1998 and 2003. Pre and post operative symptoms and numbers returning to rugby after surgery were assessed.

Results: Neck pain was eradicated in eight (42%) of the players, nine (47%) achieved partial relief and two were not helped. Brachalgia was eradicated in fifteen (79%) individuals, improved in two (10.5%) and two (10.5%) had no relief. Fourteen (74%) returned to rugby union, the majority at six months post operatively (range – five to 17 months). Thirteen (68.5%) returned to their pre-operative level of rugby; one dropped to a lesser division and five have never played rugby again (three due to physical inability, one due to club reluctance to insure and one because of a separate injury). Two of the players that returned to rugby have subsequently retired because of neck symptoms. They played three and two years post-operatively at first-class level.

Conclusion: Return to rugby union after anterior cervical discectomy is both likely and safe and therefore need not be a career ending procedure.

Objective: Surgical correction of scoliosis in small stature children is challenging due to the profile of the posterior instrumentation traditionally available. Concerns are also raised with the use of 5 mm rods for posterior correction. The Paediatric USS is a small stature System.

We studied the correction achieved and the maintenance of the correction at a minimum 15 months follow up using the Paediatric USS.

Design: 20 patients with a minimum 15 months follow up were included in the study. Measurements were made for the initial correction of the Cobb angle to assess correction. At 15 months follow up the cobb angle was measured to assess maintenance of correction.

Results: The average age of the patients was 12 ½ years. The average weight was 32 kgs. The commonest etiology was paralytic(40%) followed by congenital (30%), idiopathic (25%) and collagen disorder (5%). King type II (45%) and type IV (35%) were the commonest type of curves. Combined anterior release and posterior stabilization and fusion was the commonest procedure performed. The average pre op Cobb angle was 77.7°, which corrected to 37.6° i.e. 49%. There was no significant loss of correction at 15 months follow-up.

Conclusions: Thus the Paediatric USS allows adequate correction of the curve and does maintain the correction achieved at a minimum 15 months follow up

Objectives: Quantitative research methods have highlighted the psychological implications of spinal deformities in adolescence. However these methods are limited in exploring the adolescent’s perception of the illness and the expectations from treatment. Hence we carried out detailed qualitative interviews with these adolescents and where applicable with their families to examine these issues

Design: Individual contact was made with the adolescents attending the spinal deformity clinic in a specialist centre in Cardiff. Following their consent an interview was carried out using a qualitative semistructured format

Subjects: A total of 10 adolescents and their families attending the spinal clinic for treatment were interviewed

Results All the adolescents and their families had sufficient information and fairly good understanding of their condition and of the treatments available. The impact the deformity had on the individual’s life was variable. Social impairment was higher in these individuals and this was reflected in their interaction with their peers. Most of the families desired an expected timetable of treatemnt and sequence of events. They also felt the lack of buddy or self help gropus. It also gave a better understanding into these teenagers perception of their condition and their attitude towards treatment

Conclusions: These issues probably need to be understood while dealing with these individuals and their families and as health professionals we need to be sensitive to these issues.

To assess the results of this technique for stabilisation of severe spondylolisthesis, 12 patients with symptomatic severe spondylolisthesis underwent this procedure. The slipped L5 vertebra was stabilized using a hollow medullary screw through the posterior part of the body of S1 into the slipped L5 body, supplemented with pedicle screws into L5 and S1 with posterolateral fusion.

At one year follow-up, all but one patient had improved in leg pain. 2 patients were aware of the prominent pedicle screws. 360° fusion was achieved without any progression of spondylolisthesis. Thus 360° fusion for severe L5-S1 spondylo-listhesis can be achieved effectively using this technique.

The purpose of this prospective study is to evaluate the benefits of intra discal electrothermal treatment (IDET) for discogenic back pain.

40 patients with chronic discogenic back pain underwent this therapy. All the patients had a failed trial of conservative treatment. Patients with a positive provocative discogram were selected for IDET. The outcome is assessed using a SF36 questionnaire pre-procedure and then at 3,6,12,18 and 24 months post-operatively.

The mean age group of the patients was 37 years (range 15–58 years). All the patients had a minimum follow up of 18 months. Out of the 40 patients 5(12.5%) had no improvement and had to undergo an interbody fusion within 6 months following IDET and hence were excluded from the study. No patient developed any neurological complications. Of the rest of the 35 patients at a minimum of 18 months follow-up 56 % (p=0.042) patients had improvement in physical function scores and 52% (p=0.034) had improvement in pain scores as per the SF36.

Conclusion: IDET appears to be an effective alternative to control pain in patients who might otherwise be candidates for spinal fusion.

Controversy exists as to whether the biomechanical properties of a 360 lumbar fusion are influenced by the order in which the anterior and posterior components of the procedure are performed.

The fusion technique used Magerl screws to effect the posterior fusion and a Syncage implant (Stratec) to effect the anterior component of the fusion.

Isolated motion segments from calf spines were tested in each of two groups of five. In the first group the posterior fusion was performed first and in the second group the anterior fusion was performed first. Loads were applied as a dead weight of 2Nm in each range of movement of the spine (flexion/extension, lateral flexion and rotation). The range of movement was measured using the Qualisys motion analysis software linked to a set of five cameras, using external marker clusters attached to the vertebral bodies. Each motion segment was tested prior to instrumentation, post anterior or posterior instrumentation and with both anterior and posterior instrumentation.

Ranges of movement following 360 instrumentation were increased in all planes tested when posterior fixation was performed first; flexion/extension 26% v 55% (p=0.020), lateral flexion 18% v 34% (p=0.382), and rotation 18% v 73% (p=0.034).

It was concluded that posterior fixation should not be performed prior to anterior fixation as this results in a significant loss of stability in both flexion/extension and rotation

Objective: Controversy exists as to whether the biomechanical properties of a 360° lumbar fusion are influenced by the order in which the anterior and posterior components of the procedure are performed.

Methods: The fusion technique used Mager screws to effect the posterior fusion and a Syncage implant (Stratec) to effect the anterior component of the fusion. Isolated motion segments from five calf spines were tested in each of two groups. In the first group the posterior fusion was performed first and in the second group the anterior fusion was performed first. Loads were applied as a dead weight of 2Nm in each range of movement of the spine (flexion/extension, lateral flexion and rotation). The range of movement was measured using the Qualisys motion analysis system, using external marker clusters attached to the vertebral bodies. Each motion segment was tested prior to instrumentation, post anterior or posterior instrumentation and with both anterior and posterior instrumentation.

Results: Ranges of movement following 360° instrumentation were decreased in all planes. When posterior fixation was performed first; flexion/extension reduced to 55% compared to 26% with anterior fixation first (p=0.020), in lateral flexion 34% v 18% (p=0.382), and in rotation 73% v 18%(p=0.034).

Conclusions: The 360° fusion construct has reduced range of movement if the anterior first approach is used as compared to posterior first approach. Posterior fixation should not be performed prior to anterior fixation as this results in a significant loss of stability in both flexion/extension and rotation.

Aim: To determine the histological changes in discs retrieved at the time of fusion following failed Intra-Discal Electrothermal Therapy (IDET).

Method: Three patients who had failed IDET treatment underwent lumbar interbody fusion. At the time of the operation the disc material and the endplate were sent for histopathology. The histological changes were compared to a degenerate disc and endplate. The staining techniques used were Haematoxylin Eosin stain, Elastic Van Geison and Alcian stains.

Results: In the post IDET specimens there was stromal disorganisation, paucity of chondrocytes and chondrocyte degeneration. These changes were seen in the nucleus pulposus, annulus fibrosis and the endplate as well. Comparatively cadaveric studies using intra-discal radiofrequency thermocoagulation showed histological change only in the nucleus pulposus.

Conclusion: The endplate changes at the cellular level can be widespread following IDET therapy, which can potentially cause alteration of its mechanical properties.

Purpose: To assess the results of this technique for stabilisation of severe spondylolisthesis.

Method: Twelve patients with symptomatic severe spondylolisthesis were treated with this technique. All the patients had significant symptoms, inspite of conservative measures. The mean duration of symptoms was 3.5 years. The fixation technique was purely done through a posterior approach, with extensive posterior decompression. Stabilisation of the slipped L₅ vertebra was achieved with a trans sacral screw. The point of entry of the screw being the posterior part of the body of S₁ and it traverses the L₅-S₁ disc space into the L₅ body. A hollow medullary screw passed over a guide wire helps achieve the fixation. This fixation is supplemented with pedicle screws into L₅ and S₁ and posterolateral bone grafting. Thus an anterior and posterior fusion was achieved and the severe slip fixed in-situ.

Results: The mean follow-up was 1 year. All but one (8%) patient had improvement in leg pain. 2(16%) patients were aware of the prominent metalwork (pedicle screws). Good 360° fusion was achieved using this technique in all the patients. There was no progression of spondylolisthesis.

Conclusion: Thus, anterior and posterior in-situ fusion for severe L₅-S₁ spondylolisthesis can be achieved effectively using a single incision via a transsacral approach.

Purpose: The purpose of this prospective study is to evaluate the benefits of this treatment for discogenic back pain.

Method: Thirty-four patients with chronic discogenic back pain underwent this therapy. All the patients had a failed trial of conservative treatment. Patients with a positive provocative discogram were selected for intra-discal electrothermal therapy (IDET). The outcome is assessed using a SF 36 questionnaire filled in pre-procedure and then at three, six, twelve and eighteen months and two years post-operatively.

Results: The mean age group of the patients was 37 years (range 15–58 years). All the patients had a minimum follow up of 12 months (range 6–2 years). Out of the 34 patients 5(14%) had no improvement and had to undergo an interbody fusion following IDET. No patient developed any neurological complications. At a minimum of one year follow-up 56% patients had improvement in physical function scores and 52% had improvement in pain scores as per the SF 36.

Conclusion: Thus IDET appears to be an effective procedure in the short-term relief of discogenic back pain in patients who otherwise might be candidates for fusion.