Retrospective study. To identify patient outcomes, in particular employment, >5-years following traumatic thoracolumbar fracture.Study design
Objectives
Patient reported outcome measures (PROMs) and psychological aspects of spinal conditions play an important role in its management. Disability benefit in the social welfare system is being closely scrutinized. The PHQ9 and GAD7 are used widely in general practice to aid assessment of depression and anxiety/somatization. To date, their use in the spinal surgery out patient setting has not been assessed. Over a one-year period the senior author saw 516 new patients. Each patient completed a standard spinal assessment questionnaire consisting of several demographic/aetiological questions and PROMs (VAS back, VAS leg, ODI/NDI, PHQ9 and GAD7). An analysis of these scores was performed.Introduction
Materials and Method
The rate of Metastatic Spinal Cord Compression (MSCC) has been increasing over recent years with increased patient survival from improved cancer treatment. MSCC presents an increasing demand for spinal surgical resources. NICE guidance was issued in 2008 to improve diagnosis and management and to prevent unnecessary delays which may result in disability. The recent advances in management of cancers coupled with improved spinal surgical approaches have improved the outcome in MSCC. Early surgery has been shown to improve restoration of function. A recent systematic review found that surgery produced superior results to radiotherapy alone for the management of MSCC. However, the quality of evidence so far is mostly from observational studies. We would like to use Bluespier to create a database of MSCC patients referred to our tertiary centre. Our database would include all adult patients referred to the spinal surgical service with MSCC. Information recorded would be the diagnosis, time of onset and imaging, comorbidities, previous interventions, clinical findings, ASIA score, mobility status, sphincteric status, Karnofsky, Tokuhashi, Tomita and Bauer scores. These scores have been shown by numerous studies to have the best predictive value for outcome following MSCC. The SINS and Boriani MSCC protocols will be collected and externally validated. Time to surgery, operative data and intra operative complications will be recorded. PROMs will include the Oswestry / Neck disability index, VAS and SF36 scores. Post operative complications, morbidity and mortality will be collected and the details of any other therapy received. We would score the patients on admission and at 3 months, 6 months and one year post operatively (if survival allows). This will be done in out patients and via postal and telephone questionnaires. The database will flag the time intervals. This database will enable us to improve the quality of care given to patients with MSCC, provide evidence to highlight the importance of prompt referral and surgical intervention, audit our care against the standards set out by NICE and establish the risks, complications and outcomes of surgical intervention in this high risk group. It will be the first study to externally validate and compare several different scoring systems and protocols (above) in the same cohort. Finally, the data can be used to perform a costing analysis for the treatment of MSCC in the NHS.
To determine whether measuring pedicle size on CT is accurate and reproducible using the WEBPACS ruler tool Radiological analysis. A human cadaveric spine along with 5 geometrical shapes were scanned using a multislice spiral CT scanner with 1mm cuts. The objects and the pedicle diameters for lumbar and thoracic vertebrae in the axial plane were measured independently using the WEBPACS ruler tool by 2 observers (to the nearest 0.1mm). The geometrical shapes and pedicle size on the skeleton were then measured using Vernier callipers by an independent third observer. All measurements were repeated a week later. Reproducibility of the measurements was assessed using Bland and Altman plots. Accuracy was assessed using the Vernier calliper measurements as the gold standard and comparing the plots. Perfect reproducibility was achieved when measuring the geometric objects with the Vernier callipers. The error of the measurement associated when measuring the pedicles was 0.5mm. The error of the measurement for the geometric objects for observers 1 and 2 was 0.5 and 0.6mm respectively, and for the pedicles it was 1.0 and 0.6mm respectively. The WEBPACS ruler on a CT scan is accurate to within 0.5-0.6mm of the true size of an object. The error for pedicle measurements is marginally higher (0.6-1.0mm) and this may reflect the fact that they are ill defined geometric shapes. Measuring pedicle size on CT for surgical planning may have implications for small pedicles when sizing them up for a good screw. Ethics approval None Interest Statement None
Pedicle screw systems are now the commonest method of achieving posterior spinal fixation. Surgical planning in spinal surgery may include measuring pedicle size to guide screw size on WEBPACS. We performed a study to determine whether measuring pedicle size on CT is accurate and reproducible using the WEBPACS ruler tool. A human cadaveric spine along with 5 geometrical shapes were scanned using a multislice spiral CT scanner with 1mm cuts. The objects and the pedicle diameters for lumbar and thoracic vertebrae in the axial plane were measured independently using the WEBPACS ruler tool by 2 observers (to the nearest 0.1mm). The geometrical shapes and pedicle size on the skeleton were then measured using Vernier callipers by an independent third observer. All measurements were repeated a week later. The WEBPACS ruler on a CT scan is accurate to within 0.5-0.6mm of the true size of an object. The error for pedicle measurements is marginally higher (0.6-1.0mm) and this may reflect the fact that they are ill defined geometric shapes. Measuring pedicle size on CT for surgical planning may have implications for small pedicles when sizing them up for a good screw.
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.
We aimed (1) to determine the factors which influence outcome after surgery for CES and (2) to study CES MRI measurements. 56 patients with evidence of a sphincteric disturbance who underwent urgent surgery (1994-2002) were identified and invited to clinic. 31 MRIs were available for analysis and randomised with 19 MRIs of patients undergoing discectomy for persistent radiculopathy. Observers estimated the percentage of spinal canal compromise and indicated whether they thought the scan findings could produce CES and whether the discs looked degenerate. Measurements were repeated after two weeks. (1) 42 patients attended (mean follow up 60 months; range 25–114). Mean age at onset was 41 years (range 24–67). 26 patients were operated on within 48 hours of onset. Acute onset of sphincteric symptoms and the time to operation did not influence the outcomes. Leg weakness at onset persisted in a significant number at follow-up (p<0.005). Bowel disturbance at presentation was associated with sexual problems (<0.005) at follow-up. Urinary disturbance at presentation did not affect the outcomes. The 13 patients who failed their post-operative trial without catheter had worse outcomes. The SF36 scores at follow-up were reduced compared to age-matched norms in the population. The mean ODI was 29, LBOS 42 and VAS 4.5. (2) No significant correlations were found between MRI canal compromise and clinical outcome. There was moderate to substantial agreement for intra- and inter-observer reproducibility. Due to small numbers we cannot make the conclusion that delay to surgery influences outcome. Based on the SF36, LBOS and ODI scores, patients who have had CES do not return to a normal status. Using MRI alone, the correct identification of CES has sensitivity 68%, specificity 80% positive predictive value 84% and negative predictive value 60%. CES occurs in degenerate discs.Conclusions
The NDI is a simple 10-item questionnaire used to assess patients with neck pain. The original validation was performed on 52 patients with neck pain and the test-retest on 17 whiplash patients with a 2-day interval. The SF36 measures functional ability, wellbeing and the overall health of patients. It is used in health economics to assess the health utility, gain and economic impact of medical interventions. Objectives were to independently validate the NDI in patients with neck pain and to draw comparison between the NDI and SF36. 160 patients with neck pain attending the spinal clinic completed self-assessment questionnaires. A second questionnaire was completed in 34 patients after a period of 1-2 weeks. The internal consistency of the NDI and SF36 was calculated using Cronbach alpha. The test-retest reliability was assessed using the Bland and Altman method and the concurrent validity between the two questionnaires was assessed using Pearson correlation. Both questionnaires showed robust internal consistency: SF36 alpha = 0.878 (se=0.014, 95%CI=0.843 to 0.906) and NDI = 0.864 (se=0.017, 95%CI=0.825 to 0.894). The NDI had significant correlation to all eight domains of the SF36 (p<0.001). The individual scores for each of the ten items had significant correlation with the total disability score (p<0.001). The test-retest reliability of the NDI was acceptable. We have shown irrefutably that the NDI has good reliability and validity and that it stands up well to the SF36.
Classification systems are used for communication, deciding/planning treatment options, predicting outcome and research purposes. The vast majority of subtrochanteric fractures are now treated with intramedullary nails, which questions the need for classification. Our objective was to assess the intra- and inter-observer reliability of the Seinsheimer, AO and Russell-Taylor (RT) classification systems and assess a new simple system (KMG). The KMG system was developed to alert the surgeon to potential hazards: Type 1 – subtrochanteric fracture (ST#) with intact trochanters. Type 2 ST# involving greater trochanter (entry point for nailing difficulty). Type 3 –ST# involving lesser trochanter (most unstable). 32 AP and lateral radiographs of subtrochanetric fractures were classified independently by 4 observers twice with a 6-week interval (2 Consultants and 2 Registrars). The observers were asked to rank the systems based on how descriptive they thought they were, whether they felt they influenced treatment plan and whether they would predict outcome. The intra- and inter-observer variation was poor in all systems. KMG gave the best inter-observer reproducibility (Kappa 0.3 to 0.6) followed by AO and RT, and then Seinsheimer. The observers felt that Seinsheimer and KMG were the most descriptive and would influence the treatment plan, and Russell-Taylor would perform worst at predicting outcomes. All of the fractures in this series united The classification systems analysed in this study have poor reproducibility and seem to be of little value in predicting outcome of intramedullary nailing. The KMG system may be of some use in alerting the surgeon to potential problems.
1 patient with a short PFNA nail sustained a fracture of the femur through the site of the distal locking bolt during the follow up period and required revision. The mobility and social function scores were significantly reduced at follow up compared to pre-operative status(p=0.001).All domains of SF36 were low compared to normative data. All 30 fractures united and there was no migration, lysis around or cut out of the helical blade.In total, 46 distal locking bolts were utilised.4 of these had migrated or become loose.
The PFNA device was developed to address problems of rotational instability in proximal femoral fractures whilst simultaneously employing a single femoral neck element. The PFNA makes use of a helical blade that compresses rather than destroys osteopaenic cancellous bone. All subtrochanteric fractures admitted to the department were treated with the PFNA (AO 31A3). Demographic and clinical data during admission was recorded and formal post-operative X-Rays performed. Outcome assessment consisted of a 4 month follow-up appointment with clinical and radiological assessments, VAS, SF36, Jensen Social Function Score and Parker Mobility Score. From April to December 2006, 46 patients were included in the study. 4 month follow up has been completed in 17 of 23 patients. The average age was 78. 11 short and 7 long nails were inserted. Four patients required open reduction and internal fixation. There were no significant intra-operative or immediate postoperative complications. 1 short nail fractured through the site of the distal locking bolt during the follow up period and required revision. At follow up, 5 patients had tenderness over the greater trochanter and 2 had leg length discrepancy. None had malrotation. Only 2 patients regained their pre-operative mobility status. The mobility and social function scores were significantly reduced at follow up compared to pre-operative status (p=0.003 and p=0.001 respectively). All domains of SF36 were low compared to normative data. The mean VAS was 3/10. All fractures united and there was no migration, lysis around or cut out of the helical blade. In total, 25 distal locking bolts were utilised. Four of these had migrated or become loose. Patients with subtrochanteric fractures do not return to pre-fracture function at 4 months post injury. The PFNA appears to work well although there may be concern about bone hold of the distal locking bolts. Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.
With the imminent introduction of the Modernising Medical Careers (MMC) post-graduate training programme, we undertook a study to assess how informed the orthopaedic Multi Disciplinary Team (MDT) and patients were with regard to the details, implementation and future implications of MMC.
At follow up significantly more females had urinary incontinence (p<
0.001) and bowel disturbance (p<
0.05), higher VAS scores (p<
0.05) and lower SF36 Pain and Energy scores (p<
0.05) than males. Urinary disturbance at presentation did not affect the outcomes. Bowel disturbance at presentation was associated with sexual problems (<
0.005) and abnormal rectal tone (p<
0.05) at follow up. Objective reduced perianal sensation at onset persisted in a significant number at follow up (21/32 patients; p<
0.05) as did leg weakness (14/23; p<
0.005). There was a weak association between delay to operation and bowel disturbance (p<
0.05) at follow up. Eight patients had faecal soiling and faecal incontinence at follow up and this was associated with sudden onset of symptoms, initial abnormal rectal tone and time to operation (p<
0.05). The SF36 scores at follow up were reduced compared to age matched norms in the population. The mean ODI was 29, LBOS 42 and VAS 4.5.
There was no relationship between repeatability and the measurement size.