Objective: To assess the treatment outcome at a minimum age of 15 years in patients who had presented with idiopathic scoliosis in infancy.

Design: Patients were recalled for full pulmonary function testing (spirometry, lung volumes and gas diffusion) and surface topography. Results were correlated with history and clinical radiographs.

Subjects: The records showed 32 patients, of whom 23 could be contacted and agreed to take part in the study. Thirteen had no other abnormality, and 9 had a variety of additional problems not thought to directly precipitate their spinal deformity. There were 13 female and 9 male and age at testing ranged from 15.2 to 30.2 years.

Outcome measures: Spirometry (forced vital capacity (FVC), forced expiratory volume in one minute (FEV₁)), lung volumes ( total lung capacity (TLC), residual volume (RV)) and gas diffusion (carbon monoxide diffusion (DLCO), and alveolar volume (VA)) were correlated with the most recent Cobb angle, surface topography and age at surgery where applicable.

Results: Those who were successfully managed without recourse to surgery (N=6) had normal cosmesis and pulmonary function (mean FEV₁ = 98.7%, mean FVC = 96.6%). When surgery had been postponed until after age 10 (N=6, mean age at surgery 12.9 years) pulmonary function showed some restriction (mean FEV₁ = 79%, mean FVC = 68.3%). Those who underwent corrective surgery before age 10 years (N=11, mean age at surgery 4.1 years) had significant recurrence of deformity and diminished respiratory function (mean FEV₁= 41%, range 14 – 72%, mean FVC = 40.8%, range 12 – 67%). There was statistically significant correlation (p< 0.01 or less) between respiratory measures on the one hand and age at surgery (where applicable), surface topography measures and latest Cobb angle.

Conclusions: It has been reported that only in early-onset scoliosis is the growth of lung tissue and the multiplication of alveoli impeded[1,2] and treatment is directed at preserving both pulmonary function and cosmesis. Early surgery is recommended on the assumption that the Cobb angle can be controlled and normal pulmonary development enabled in those whose scoliosis did not respond to conservative methods. Methods have changed since the earlier cases in this series were treated, and it is hoped that later results will be different. However, caution requires that, in monitoring these patients, cosmesis and, more importantly, respiratory function be considered before a conclusion is drawn.

Langerhans-cell histiocytosis (LCH) is a reactive proliferative disease characterized by the accumulation of abnormal histiocytes. The disease is broadly divided into two groups, unisystem and multisystem disease. The aetiology of LCH is unknown; the disease is currently accepted to be a reactive process rather than a malignancy. Localized LCH of bone is a benign tumour-like condition, which is characterized by a clonal proliferation of Langerhan’s-type histocytes, which infiltrate bone and cause osteolytic lesions. The common bones involved include – skull, pelvis, and diaphysis of long bones.

We wanted to determine whether patient demographics at the time of presentation could help determine the clinical course and eventual outcome of the disease. We prospectively reviewed 68 patients with a primary diagnosis of LCH.

Forty-six patients had unisystem disease, 22 had multisystem disease. There was a statistically significant difference in the age of presentation between the two groups. There were 6 deaths, all had multisystem disease. Of the 46 patients with unisystem disease, 31 (67.3%) underwent orthopaedic surgical intervention, 26 open biopsies and 5 curettage and bone grafting of lesions of the humeras (2), skin, clavicle and skull (1 each). There was a statistically significant difference in the average length of follow-up, between the 2 groups.

We recommend closed and prolonged multidisciplinary follow-up of patient initially presenting with multisystem disease. Patients with unisystem disease can safely be discharged after a short follow-up period.

Objective: It is frequently said that the natural history of adolescent idiopathic scoliosis (AIS) is not understood. This study examines clinical data collected over some years and shows that the information is available and needs only to be generalised and applied.

Design: Retrospective analysis of data, relating basic clinical information (age, Cobb angle, pubertal status, growth) to outcome in the practical terms that are relevant to clinical practice and patient management, Subjects: Two groups of female patients identified from the database: Group 1, girls diagnosed at least one year before the onset of menses and last reviewed at least one year afterwards; Group 2, girls diagnosed at least one day after menarche, followed for at least one year and not having surgery as a first option i.e. within six months.

Outcome measures: Within and between group comparisons as regards age, height and Cobb angle at presentation and at last review and age at menarche. Change in height and Cobb angle of 10°, and the incidence of non-operative treatment and corrective surgery were considered. Statistical analysis was by student’s t test and Fisher’s exact.

Results: Group 1 (N=58) presented at a mean age of 11.6 years SD 1.02, range 10 – 13.9 and reached menarche a mean of 2.1 years later, SD 0.86, range 1.0 – 4.5. Mean Cobb angle was 16.79 SD 8.58. Progression of more than 10° was observed in 24 girls, 11 of whom underwent surgery. Those who progressed had a higher initial Cobb angle (p=0.01) and were taller at discharge (p=0.041), but all other parameters were the same. Group 2 (N=92) presented at a mean age of 13.7 years SD 0.92 with a mean Cobb angle of 23.77° SD 14.52. Progression of 10° or more was observed, one of whom had surgery, her Cobb angle having increased from 48° to 64°. 6 had surgery for cosmetic reasons without further increase in Cobb angle. There was no statistically significant difference between the stable and progressive groups on any parameter other than final Cobb angle.

Comparing Groups 1 & 2, girls in Group 1 were younger and smaller at diagnosis with lower Cobb angles. They were older at menarche, but this was inevitable from the selection criteria, and more likely to progress (p< 0.001), to receive a brace (p=0.047) and to undergo surgery (p=0.043). Age, final Cobb angle and height at discharge were not significantly different.

Conclusions: 1.Girls diagnosed with AIS before puberty are at increased risk of progression but this is not usually clinically significant and does not usually lead to corrective surgery. 2.Girls diagnosed after menarche progress rarely and less. In practice, their deformity can be taken as stable at presentation. 3. In most cases, the course is benign and non-operative treatment had no discernible effect on outcome. As the percentage progressing significantly or requiring treatment at any stage is small, a less interventionist approach is indicated.

The Extensor Digitorum Brevis is an easily visualised superficial muscle present on the dorsolateral aspect of the foot. It is innervated by the terminal branches of L5. Wasting of this muscle has been described as a sign of L5 radiculopathy, however its specificity and sensitivity as a clinical sign in patients with disc disease has never been assessed to the best of our knowledge.

The purpose of our study was to determine the effectiveness of this sign in patients with a know L5 radiculopathy. We included three groups of patients, which were prospectively assessed by a blinded single examiner. Group A were patients with a clinical L5 radiculopathy confirmed on MRI, Group B were patients with a clinical a S1 radiculopathy confirmed on MRI and Group C were a control group. There were 20 patients in each group, 10 male and 10 female, mean age 38 years (range 19 – 57 years). Our inclusion criteria were leg pain greater than 6 weeks, we excluded and patient with a history of previous disc disease or foot surgery. A positive sign was defined as a gross clinical wasting of the extensor digitorum brevis compared to the opposite foot.

The sign was negative in all 20 patients in the control group. The sign was positive in 12 patients (60%) with L5 radiculopathy and only one patient (5%) with S1 radiculopathy. Fishers exact test confirmed statistical significance between the two groups with a p value of < 0.05.

We conclude that this easily performed objective clinical sign, when used inpatients with leg pain, is highly specific in determining the pressure of an L5 root involvement.

Introduction: The arguments for and against school screening for scoliosis are long since over, and centres have continued or ceased as they thought best and as funding allowed. However, the programmes did amass considerable volumes of observations that, being part of the over-all epidemiological picture, could advance our understanding of adolescent idiopathic scoliosis and of minor asymmetries of back shape.

Methods and Results: A retrospective examination of the records from the school screening programme at this centre concentrated on subjects with minor asymmetry, those who at first review did not qualify as ‘scoliosis’ yet were noted to have failed the forward bend test. There were 91,811 examinations on 55,484 girls: 2170 were classified as ‘non-scoliosis asymmetry’. Of these, 1574 were noted but not referred; 360 were reviewed in clinic without radiograph,; 107 had straight spines on radiograph and 221 had Cobb angles < 10°. Eleven are known to have progressed to 10° or more, three passed 25°, two passed 40° and one underwent surgery. This gives an incidence in this subgroup of 0.51% for defined scoliosis. For scoliosis => 25°, it was 0.14%; for scoliosis => 40°, 0.092%; and 0.046% for surgery, none of which shows a significant difference from the equivalent rates for the population as a whole. (0.6% Cobb angle => 10°, 0.2% Cobb angle => 25°, 0.08% Cobb angle => 40°, 0.045% surgery. (Goldberg CJ et al. (1995). Spine. 20(12):1368–1374).

Conclusion: These findings are in accordance with previous reports on school screening, and it is not proposed to re-open the discussion. Their relevance is their relationship to significant scoliosis: since these children are not at increased risk of developing deformity, they cannot be, as has been proposed (Nissinen et al (2000) Spine. 25:570–574) instances of mild or early scoliosis, and they do not need intensive investigation, follow-up or treatment. Non-scoliosis asymmetry is closer to the increased fluctuating asymmetry displayed by this age group (Wilson and Manning. (1996) Journal of Human Evolution. 30:529–537) and begs a more biological approach to spinal deformity, asymmetry and back shape.

Introduction: Historically, the spinal curvature of adolescent idiopathic scoliosis was considered a life-threatening occurrence, which would result in early death from cardio-respiratory compromise. Consequently, corrective surgery had the primary intention of preventing this unacceptable outcome: cosmetic improvement was considered to be certainly important, but not the prime objective of the treatment. More recent work (e.g. Branthwaite MA. (1986) Br.J.Dis.Chest. 80:360–369) has shown that, while significant deformity presenting in early childhood does carry this outlook, those with an adolescent onset should not be significantly affected in this way. Consequently, any surgery recommended is primarily cosmetic, to improve the deformity when it is unacceptable to the patient and her parents. This, of necessity, changes the criteria by which treatment outcome should be assessed. Scoliosis surgery has generally been judged by the correction in Cobb angle and, more recently, the derotation of vertebrae. However, it is well known that neither factor accurately expresses cosmesis, the criterion by which the patient will judge the operation. Surface topography attempts to quantify the external appearance of a patient and so the cosmetic effect of surgery. Since 1995, when a surface topographic system (Quantec) was acquired by this department, 61 patients were operated for adolescent idiopathic scoliosis, of whom 35 underwent anterior release and posterior fusion for rigid thoracic curves.

Methods and Results: Pre- and post-operative radiographs were compared with topographic results from the same periods and with the latest scan at last review. The mean pre-operative Cobb angle was 74.5° and, postoperatively was 40.7°, a mean correction of 45.4% and was statistically significant (p< .001). This was accompanied by statistically significant reductions in upper and middle topographic spinal angles (p=0.001), an increase in thoracic kyphosis (p< 0.05), a decrease in lumbar lordosis (p=0.001), lower rib hump (p< 0.05), Suzuki hump sum (a measure of back asymmetry, p=0.001) and posterior trunk asymmetry score (POTSI, a measure of trunk balance, p=0.003). At final follow-up a mean of 2.2 years later, topographic spinal angles and POTSI maintained their improvement, still being statistically significantly less than their pre-operative values. Thoracic kyphosis, lumbar lordosis, rib hump and Suzuki hump sum had returned towards pre-operative levels and no longer showed statistically significant differences.

Conclusions:This confirms previous reports of the recurrence of the rib-hump. In conclusion, after two-stage spinal fusion for adolescent idiopathic scoliosis, significant improvement in cosmetic appearance can be achieved. However, over time certain aspects of the original deformity, particularly distortion of the back surface (rib hump or asymmetry) recurs.

Posterior lumbar interbody fusion is a well described procedure for the treatment of back pain associated with degenerative disc disease and segmental instability. It allows decompression of the spinal canal and circumferential fusion through a single posterior incision.

Sixty-five consecutive patients who underwent posterior lumbar interbody fusion (PLIF) using carbon cages and pedicle fixation between 1993 and 2000 were recruited and contacted with a postal survey.

Clinical outcome was assessed by the assessment of postoperative clinical findings and complications and the fusion rate, which was assessed using standard X-rays with the scoring system described by Brantigan and Steffee. Functional outcome was measured by using improvement in the Oswestry Disability Index, PROLO score, return to work and satisfaction with the surgical outcome. The determinants of functional relief were analysed against the improvement in disability using multiple regression analysis.

The mean postoperative duration at the time of the study was 4.4 years. The response rate to the survey was 84%. Overall radiological fusion rate was ninety eight percent. There was a significant improvement in Oswestry Disability Index P< 0.001. There was 85% satisfaction with the surgical procedure and 58% return to pre-disease activity level and full employment. In the presence of near total union rate we found preoperative level of disability to be best the determinant of functional recovery irrespective of age or the degree of psychological morbidity (p< 0.0001).

The combination of posterior lumbar interbody fusion (PLIF) and posterior instrumented fusion is a safe and effective method of achieving circumferential segmental fusion. This procedure gives sustained long-term improvement in functional outcome and high satisfaction rate. Direct relationship between preoperative level of disability and functional recovery suggests that spinal fusion should be performed to alleviate disability caused by degenerative spine.

Assessment and referral of spinal disease in a primary care setting is a challenge for the general practitioner. This has led to establishment of spinal assessment clinic to insure prompt access to the patient who requires treatment by a spinal surgeon. These clinics are run by a trained physiotherapist who liaises with a member of the spinal team and decides the need for referral to the spinal clinic on the bases of the patient’s history and clinical examination. In our clinic each patient is also assessed with Oswestry disability index, Short form-36, visual analogue score and hospital anxiety score (HADS), although these scores do not contribute to the clinical decision-making. The aim of this study is to assess the screening value of Oswestry disability score, Short form-36 scores in diagnosing acute spinal pathology.

Sixty-nine patients who were referred to the spine clinic from the assessment clinic between March and December 2001 were recruited. Sixty-nine age and sex-matched patients were randomly chosen from five hundred and twelve patients who were seen in the spinal assessment clinic and did not need referral to the specialised spine clinic. The Oswestry disability score, Short form-36 scores and pain visual analogue scores between the two groups were statistically compared. The correlation between the level of psychological morbidity, length of symptoms and presence of past history of symptoms against the level of disability was statistically assessed.

Although there was a significant increase in the level of disability in the referred group with each score (Oswestry Disability Score P< 0.001, SF-36 physical component score P=0.014, Visual analogue pain score P< 0.001). The variation in the scores makes the scoring system unspecific for use as a screening tool. We also found strong relationship between psychological disability and length of symptoms indicating the need for prompt treatment for back pain.

Neonatal septic arthritis is a true orthopaedic emergency posing significant threat to life and limb.

Objective: To examine the clinical presentation, diagnosis, treatment and outcome of children presenting with septic arthritis in the neonatal period.

Design: Retrospective review of clinical notes and radiographs of children presenting over a 20 year period (1977–97).

Subjects: 34 patients with septic arthritis in a total of 36 joints.

Outcome measures: Clinical outcome was classified as satisfactory or unsatisfactory as per Morrey et al. Radiological outcome was graded I–IV as per Choi et al. Joint instability, destruction, limb length discrepancy and angular deformity were assessed.

Results: The hip joint was affected in 24 of the 34 cases. Pseudoparalysis was the most reliable clinical finding occurring in 29 out of 34 cases. Staph Aureus was isolated as the infecting pathogen in 22/34 patients. Sequelae occurred in 16 hips and 1 knee. Poor prognostic indicators were delayed diagnosis (p< 0.05) and the hip as site of infection (p< 0.01). Clinical outcome was unsatisfactory in 15 patients and satisfactory in 17 patients. Radiological outcome was Choi I or IIA (good) in 12 hips and Choi II to IV in 13 hips (poor). Multiple further reconstructive procedures were required in 15 cases.

Conclusions: Despite optimum treatment, neonatal septic arthritis results in significant long-term morbidity for a high proportion of cases.

The role of nucleus pulposus (NP) biology in the genesis of sciatica is being increasingly investigated.

The aim of this study was to examine the ability of control and degenerate human nucleus pulposus to respond to an exogenous pro-inflammatory stimulus.

Control disc material was obtained from surgical procedures for scoliosis and degenerate disc tissue from surgical procedures for sciatica and low back pain. Disc specimens were cultured using a serumless technique under basal and lipopolysaccharride (LPS) stimulated conditions and the media harvested, aliquoted and stored at –80°C for subsequent analysis. Levels of IL-1β,TNFα, LTB4, GM-CSF, IL-6, IL-8, MCP-1, PGE2, bFGF and TGFβ-1 in the media were estimated using commercially available enzyme linked immunoabsorbent assay kits.

Neither basal nor LPS stimulated control or degenerate NP produced detectable levels of IL-1β, TNFα, LTB4 or GM-CSF. Control disc IL-8 secretion increased significantly with LPS stimulation, p< .018. Degenerate disc IL-6, IL-8 and PGE2 production increased significantly with LPS stimulation, p< .01, p< .001 and p< .005 respectively. LPS stimulated degenerate NP secreted significantly more IL-6, IL-8 and PGE2 than LPS stimulated control NP, p < 0.05, 0.02 and 0.003 respectively.

LPS induces an increase in both control and degenerate NP mediator production demonstrating the ability of human NP to react to a noxious stimulus by producing pro-inflammatory mediators. The difference in levels of basal and LPS stimulated mediator production between control and degenerate discs show that as a disc degenerates it increases both its level of inflammatory mediator production and its ability to react to a pro-inflammatory stimulus. The increased sensitivity of degenerating human NP to noxious stimuli and increased ability to respond with inflammatory mediator production support the role of NP as an active participant in the genesis of lumbar radiculopathy and discogenic back pain.

Posterior lumbar interbody fusion is a well-described procedure for the treatment of back pain associated with degenerative disc disease and segmental instability. It allows decompression of the spinal canal and circumferential fusion through one posterior incision. The aim of this study is to assess fusion rate as well as long term outcome of this procedure.

Methods: Fifty-six consecutive patients who underwent posterior lumbar interbody fusion (PLIF) using carbon cages and pedicle fixation between 1993 and 2000 were recruited and contacted with postal survey. Clinical outcome was measured using changes in Oswestry Disability Index (before the surgery and at the time of the study) and patient questionnaire containing pain improvement, analgesic use, return to work and satisfaction with surgical outcome.

Fusion rate was assessed using standard X-rays with scoring system described by Brantigan and Steffee.

Results: The average age of the patients at the time of surgery was 43 years. The complication involved one misplaced pedicle screw, one dural tear, one deep infection, one displacement of the cage and one pulmonary embolism. The mean postoperative duration at the time of the study was 4.4 years. The response rate to the survey was 84%. Overall radiological fusion rate was 94%. There was a significant improvement in Oswestry Disability Index P< 0.001. Eighty five percent of the patients were satisfied with their surgical outcome and fifty eight percent of the work eligible patients had resumed their pre-disease activity level and full employment.

Conclusions: The combination of posterior lumbar inter-body fusion (PLIF) with posterolateral instrumented fusion is a safe and effective method of achieving circumferential segmental fusion. This procedure gives sustained long-term improvement in functional outcome and high satisfaction rate.

An initial report from an acute back pain screening clinic, the first of its kind in Ireland, run by two Chartered Physiotherapists under the supervision of a Consultant Spinal Surgeon. Patients are referred directly from their Primary Care Practitioners and the A& E Department. The objectives of the clinic are to fast track patients with spinal pathology requiring specialist treatment, identify patients requiring other treatments/ interventions and ultimately to attempt to prevent the development of the chronic back pain syndrome. Since March 2001, approximately 800 patients with acute low back pain of duration greater than 6 weeks and less than 1 year have been seen at this clinic. 30% were referred for formal physiotherapy, 11% to the orthopaedic spinal clinic, 1% to the specialist pain clinic and 30% were discharged following simple advice and education.

Study Objective: To assess patient and General Practitioner satisfaction with this service.

Design: A validated patient satisfaction questionnaire for back pain was administered to 100 consecutive patients who had attended the clinic at least 6 months previously. 70 General Practitioners who had utilised the service were asked to complete a further questionnaire.

Results: The response rate was 73% from the patients and 66% from GP’s. Patients reported satisfaction with the treatment, advice and information received at the clinic but felt more investigations were warranted. GP’s were pleased with the accessibility of the service but expressed reservations about the quality of correspondence from the clinic.

Conclusions: The back pain screening clinic represents an important development in the services available for those with acute low back pain as demonstrated by the satisfaction of both those referring to and attending the clinic.

The pathophysiology of discogenic low back pain is poorly understood. The morphological changes occurring in disc degeneration are well documented but unhelpful in determining if a particular degenerate disc will be painful or not.

Herniated intervertebral disc tisssue has been shown to produce a number of pro-inflammatory mediators and cytokines. No similar studies have to date been done utilising disc material from patients with discogenic low back pain.

The aim of this study was to compare levels of production of interleukin-6 (IL-6), interleukin-8 (IL-8) and Prostaglandin E2 (PGE2) in disc tissue from patients undergoing discectomy for sciatica with that from patients undergoing fusion for discogenic low back pain.

Tissue from 50 patients undergoing discectomy for sciatica and 20 patients undergoing fusion for discogenic low back pain was cultured and the medium harvested for subsequent analysis using an enzyme linked immunoabsorbent assay method. Statistical analysis of the results was performed using the Mann-Whitney test.

Disc specimens from both experimental groups produced measurable levels of all three mediators. Mean production of IL-6, IL-8 and PGE2 in the sciatica group was 26.2±75.7, 247±573 and 2255±3974 respectively. Mean production of IL-6, IL-8 and PGE2 in the low back pain group was 92±154, 776±987 and 3221±3350 respectively (data = mean production pg/ml ± 1 standard deviation).

There was a statistically significant difference between the levels of IL-6 and IL-8 production in the sciatica and low back pain groups (p< 0.006 and p< 0.003 respectively).

The high levels of pro-inflammatory mediator production found in disc tissue from patients undergoing fusion for discogenic LBP may indicate that nucleus pulposis pro-inflammatory mediator production is a major factor in the genesis of a painful lumbar disc. This could explain why some degenerate discs cause LBP while other morphologically similar discs do not.

Surgical correction of spinal deformity in patients with neural axis abnormalities has established risks of causing further neurological injury. It is necessary to identify individuals with a predisposition for such abnormalities before treatment is instituted.

Objective: Examination of the association between idiopathic scoliosis and underlying neural axis abnormalities in the infantile and juvenile age groups.

Design: Retrospective chart and radiographic review.

Subjects: Ninety-four (36 infantile, 58 juvenile) consecutive patients with non-congenital scoliosis under the age of eleven years.

Outcome measures: These consisted of the MRI findings, neurological examination, associated curve morphology and necessity for neurosurgical intervention or surgical curve correction.

Results: Approximately 25% of patients presenting as idiopathic juvenile scoliosis had underlying neural axis abnormalities. No patient with apparent infantile idiopathic scoliosis had an abnormal spinal MRI scan. Using the Z score for independent proportions, there was a statistically significant difference between infantile and juvenile scoliosis and the presence of an underlying neural axis abnormality (Z score of 2.089, equivalent to p< 0.02).

Conclusions: We advocate routine MR spinal imaging in all patients with juvenile idiopathic scoliosis. In infantile idiopathic scoliosis, to avoid unnecessary general anaesthetics, one should image the spinal canal only when clinically indicated