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.

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.

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.

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

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.

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.

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.