Scoliosis is a lateral curvature of the spine with associated rotation, often causing distress due to appearance. For some curves, there is good evidence to support the use of a spinal brace, worn for 20 to 24 hours a day to minimize the curve, making it as straight as possible during growth, preventing progression. Compliance can be poor due to appearance and comfort. A night-time brace, worn for eight to 12 hours, can achieve higher levels of curve correction while patients are supine, and could be preferable for patients, but evidence of efficacy is limited. This is the protocol for a randomized controlled trial of ‘full-time bracing’ versus ‘night-time bracing’ in adolescent idiopathic scoliosis (AIS). UK paediatric spine clinics will recruit 780 participants aged ten to 15 years-old with AIS, Risser stage 0, 1, or 2, and curve size (Cobb angle) 20° to 40° with apex at or below T7. Patients are randomly allocated 1:1, to either full-time or night-time bracing. A qualitative sub-study will explore communication and experiences of families in terms of bracing and research. Patient and Public Involvement & Engagement informed study design and will assist with aspects of trial delivery and dissemination.Aims
Methods
Current clinical treatment for spinal instability requires invasive spinal fusion with cages and screw instrumentation. We previously reported a novel injectable hydrogel (Bgel), which supports the delivery and differentiation of mesenchymal stem cells (MSCs) to bone forming cells and supports bone formation Bovine and Human Nucleus pulpous tissue explants were injected with Bgel with and without MSCs. Tissue samples were cultured under hypoxia (5%) in standard culture media for 4 weeks. Cell viability, histological assessment of matrix deposition, calcium formation, and cell phenotype analysis using immunohistochemistry for NP matrix and bone markers.Background
Methodology
Thermal sensors have been used in bracing research as self-reported diaries are inaccurate. Little is known about new low-profile sensors, optimal location within a brace, locational thermal micro-climate and effect of brace lining. Our objective is to Determine an optimal temperature threshold for sensor-measured and true wear time agreement. Identify optimal sensor location. Assess all factors to determine the best sensor option for the Bracing AdoleScent Idiopathic Scoliosis (BASIS) multicentre RCT. Seven Orthotimer and five iButton (DS1925L) sensors were synchronised to record temperature at five-minute intervals. Three healthy participants donned a rigid spinal brace, embedded with both sensors across four anatomical locations (abdomen/axilla/lateral-gluteal/sacral). Universal-coordinated-time wear protocols were performed in/out-doors. Intraclass correlation coefficient (ICC) assessed sensor-measured and true wear time agreement at thresholds 15–36oC. Optimal thresholds, determined by largest ICC estimate: Orthotimer: Abdomen=26oC, axilla=27oC, lateral-gluteal=24.5oC, sacral=22.5oC. iButton: Abdomen=26oC, axilla=27oC, lateral-gluteal=23.5oC, sacral=23.5oC. Warm-up time and error at optimal thresholds increased for moulded sensors covered with 6mm lining. Location: anterior abdominal wall. Excellent reliability and higher optimal thresholds, less likely to be exceeded by ambient temperature; not a pressure area. Sensor: iButton, longer battery life and larger memory than Orthotimer; allows recording at 10 min intervals for life of brace. Orthotimer only able to record every 30 mins, increasing error between true and measured wear time; Orthotimer needs 6-monthly data download. Threshold: 26oC is optimal threshold to balance warm-up and cool-down times for accurately measuring wear time. Sensor should not be covered by lining foam as this significantly prolongs warm-up time.
Injectable hydrogels via minimally invasive surgery offer benefits to the healthcare system, reduced risk of infection, scar formation and the cost of treatment. Development of new treatments with the use of novel biomaterials requires significant pre-clinical testing and must comply with regulations before they can reach the bedside. In the European economic area (EEA) one of the first hurdles of this process is attaining the CE marking which protects the health, safety and environmental aspects of a product. Implanted materials fall under the class III medical device EU745 regulation standards. To attain the CE marking for a product parties must provide evidence of the materials safety with an investigational medicinal product dossier (IMPD). We have been working to develop a new thermoresponsive injectable biomaterial hydrogel (NPgel) for the treatment of intervertebral disc (IVD) disease. A large part of the IMPD requires information on how the hydrogel physical properties change over time in bodily conditions. We have been studying 6 batches of NPgel over 18 months, tracking the materials wet/ dry weight, structure and composition. To date we have found that NPgel in liquids more similar to the body (with protein and salts) appear to be stable and safe, whilst those in distilled water swell and disintegrate over time. Subtle long-term changes to the material composition were found and we are currently investigating its ramifications.Introduction
Methods and Results
Low back pain is the leading cause of musculoskeletal disease and the biggest cause of morbidity worldwide. Approximately 40% of these are cases are caused by disease of the intervertebral discs (IVDs): the shock absorbing, flexible material located between the bones (vertebrae) along the length of the spine. In severe cases, the spine becomes unstable and it becomes necessary to immobilise or fix the joint in position using a lumbar cage spacer between in the IVD and metal pins with supporting plates in the vertebrae. This is a complex, expensive, major surgery and it is associated with complications, such as spinal fusion failure and inappropriate implant position. These complications have a dramatic impact on the quality of life of the affected patients and the burden to society and the healthcare system is exacerbated. We present an Introduction
Methods and Results
We have previously reported the development of injectable hydrogels for potential disc regeneration (NPgel) or bone formation which could be utilized in spinal fusion (Bgel). As there are multiple sources of mesenchymal stem cells (MSCs), this study investigated the incorporation of patient matched hMSCs derived from adipose tissue (AD) and bone marrow (BM) to determine their ability to differentiate within both hydrogel systems under different culture conditions. Human fat pad and bone marrow derived MSCs were isolated from femoral heads of patients undergoing hip replacement surgery for osteoarthritis with informed consent. MSCs were encapsulated into either NPgel or Bgel and cultured for up to 6 weeks in 5% (NPgel) or 21% (Bgel) O2. Histology and immunohistochemistry was utilized to determine phenotype. Both fat and bone marrow derived MSCs, were able to differentiate into both cell lineages. NPgel culture conditions increased expression of matrix components such as collagen II and aggrecan and NP phenotypic markers FOXF1 and PAX1, whereas Bgel induced expression of collagen I and osteopontin, indicative of osteogenic differentiation.Purpose of study and background
Methods and Results
IVD degeneration is a major cause of Low back pain. We have previously reported an injectable hydrogel (NPgel), which induces differentiation of human MSCs to disc cells and integrates with NP tissue following injection MSCs were cultured in NP gel under 5% O2 in either: standard culture (DMEM, pH7.4); healthy disc (DMEM, pH7.1); degenerate disc (low glucose DMEM, pH6) or degenerate disc plus IL-1β. Following 4 weeks histological staining and immunohistochemical analysis investigated viability, ECM synthesis and matrix degrading enzyme expression. Here we have shown that viability and NP cell differentiation of MSCs incorporated within NPgel was mostly unaffected by treatment with conditions such as low glucose, low pH and the presence of cytokines, all regarded as key contributors to disc degeneration. In addition, the NPgel was shown to prevent MSCs from displaying a catabolic phenotype with low expression of degradative enzymes, highlighting the potential of NPgel to differentiate hMSCs and protect them from the degenerate disc microenvironment.Purpose of study and background
Methods and Results
The intervertebral disc (IVD) is a highly hydrated and hyperosmotic tissue, water and salt content fluctuate daily due to mechanical loading. Resident IVD cells must adapt to this ever-changing osmotic environment, to maintain normal behaviour. However, during IVD degeneration the disc becomes permanently dehydrated and cells can no longer perform their correct function. Here, we investigated how human nucleus pulposus (NP) cells respond to altered osmolality with regards to cell size and the rate of water permeability, along with the potential involvement of aquaporins (AQPs) and transient receptor potential vanilloid (TRPV) membrane channels. Water permeability of NP cells exposed to altered osmolality (225–525mOsm/kg) in the presence or absence of AQP and TRPV channel inhibitors was investigated with the cell-permeable calcein-AM fluorescent dye, and cell size determined using microscopy and flow cytometry.Introduction
Methods
Intervertebral disc (IVD) degeneration is a major cause of low back pain (LBP). We have developed an injectable hydrogel (NPgel), which following injection into bovine IVD explants, integrates with IVD tissue and promotes disc cell differentiation of delivered mesenchymal stem cells (MSCs) without growth factors. Here, we investigated the injection of NPgel+MSCs into IVD explants under degenerate culture conditions. The NPgel integrated with bovine and human degenerate Nucleus Pulposus (NP) tissue and hMSCs produced matrix components: aggrecan, collagen type II and chondroitin sulphate in standard and degenerate culture conditions. Significantly increased cellular immunopositivty for aggrecan was observed within native NP cells surrounding the site where NPgel+MSCs were injected (P≤0.05). In NP explants a significant decrease in catabolic factors were observed where NPgel+MSCs was injected in comparison to controls.Background
Methods and Results
To investigate the feasibility of undertaking a definitive Randomised Controlled Trial (RCT) to determine the effectiveness of early physiotherapy for sciatica. Patients over 18 presenting to their G.P with sciatica were eligible to participate in the study, those without a clear understanding of English or had co-morbidities preventing rehabilitation were ineligible. Process and patient reported outcomes including self-rated disability, pain and general health, were collected at baseline, 6,12 and 26 weeks post randomisation. Participants were randomised into either early physiotherapy, receiving treatment within 2 weeks after randomisation or usual care with physiotherapy commencing 6 weeks post randomisation. Both groups received up to 6 treatment sessions of a patient-centred, goal orientated physiotherapy programme specific to their needs.Purpose of the study
Methods
The aims of the study were to explore the experiences of sciatica sufferers, their perceptions of physiotherapy and healthcare service provision. This was the qualitative element of a mixed methods study investigating the feasibility of early physiotherapy for sciatica. Participants in the pilot trial consented to take part in semi-structured interviews before and after they had undertaken an individualised physiotherapy programme. Data from the interviews was examined line by line using a thematic analysis approach with key themes and sub-themes emerging.Purpose of the study
Methods
During development the central disc contains large, vacuolated notochordal (NC) cells which in humans are replaced by mature nucleus pulposus (NP) cells during aging, but are maintained in certain breeds of dogs. During degeneration the disc becomes less hydrated which affects its normal function. Aquaporins (AQP) are a family of 13 transmembrane channel proteins that allow passage of water and are responsible for maintaining water homeostasis. AQP1, 2, 3 and 5 have been identified in the intervertebral disc (IVD). Here, expression of AQPs in human and canine IVDs to determine expression in NC v/s NP cells and whether expression changes during degeneration. Gene expression of all 13 AQPs, were investigated in 102 human NP samples using RT-qPCR. AQPs which were expressed at gene level were further investigated by Immunohistochemistry in human and canine IVD samples.Introduction
Methods
Intervertebral disc (IVD) degeneration is a major cause of Low back pain (LBP). We have reported an injectable hydrogel (NPgel), which following injection into bovine NP explants, integrates with NP tissue and promotes NP cell differentiation of delivered mesenchymal stem cells (MSCs) without growth factors. Here we investigated the injection of NPgel+MSCs into bovine NP explants under degenerate culture conditions to mimic the hMSCs were incorporated within liquid NPgel and injected into bovine NP explants alongside controls. Explants were cultured for 6 weeks under hypoxia (5%) with ± calcium 5.0mM CaCl2 or IL-1β individually or in combination to mimic the degenerate microenvironment. Cell viability was assessed by caspase 3 immunohistochemistry. Histological and immunohistochemical analysis was performed to investigate altered matrix synthesis and matrix degrading enzyme expression.Background
Methods
Within the intervertebral disc (IVD), nucleus pulposus (NP) cells reside within a unique microenvironment. Factors such as hypoxia, osmolality, pH and the presence of cytokines all dictate the function of NP cells and as such the cells must adapt to their environment to survive. Previously we have identified the expression of aquaporins (AQP) within human IVD tissue. AQPs allow the movement of water across the cell membrane and are important in cellular homeostasis. Here we investigated how AQP gene expression was regulated by the microenvironment of the IVD. Human NP cells were cultured in alginate beads prior to cytokine, osmolality, pH and hypoxia treatments and subsequent RT-qPCR to assess regulation of AQP gene expression.Introduction
Methods
The intervertebral disc (IVD) is a highly hydrated tissue which is reduced during degeneration leading to loss of function. Aquaporins (AQP) are a family of 13 (AQP0-12) transmembrane channel proteins that selectively allow the passage of water and other small molecules in and out of cells and are responsible for maintaining water homeostasis. AQP1, 2, 3 and 5 have been identified in the IVD. Here gene and protein expression of all 13 AQPs was investigated in a large cohort of human IVDs to investigate expression during IVD degeneration. Gene expression of all 13 AQPs was investigated in non-degenerate and degenerate tissue from 102 human NP samples using RT-qPCR. AQPs which were expressed at gene level were further investigated in 30 IVD samples by Immunohistochemistry.Introduction
Methods
The primary aim of this pilot study was to assess and evaluate the SpineCor Pain Relief Brace as a method of reducing the pain experienced by patients diagnosed with degenerative scoliosis Participants (n=24) with an average age of 67 (+/− 8) old that fulfilled the study inclusion criteria were randomly allocated into either a treatment or control group. Both sets of participants received questionnaires (ODI, SF 36v2 and EQ5D-5L) at 1,3,6,9 and 18 months. In addition to the questionnaires the treatment group also received the SpineCor Pain Relief Brace and took part in a semi structured interview.Aim
Method
This study aimed to verify the accuracy of the DIERS Formetric Scan when assessing vertebral rotation of the apical vertebrae in Adolescent Idiopathic Scoliosis (A.I.S) patients, to determine whether the DIERS Formetric Scans can be used instead of or alongside radiographs when assessing A.I.S patients. Both the radiographs and the DIERS Formetric Scans of 60 Preoperative A.I.S patients. All patients included in our study had predominant thoracic curves using the Lenke classification method, Cobb angle range 33° – 85°. Each radiograph was categorised into groups according to the severity of Nash-Moe rotation score of the apical vertebrae. Three groups were formed Nash-Moe +1 (20 patients), Nash-Moe +2 (27 patients), Nash-Moe +3 (13 patients). Each result was then compared to the maximal rotation analysed by the DIERS Formetric Scan, which took place on the same day as the radiographs. The results were then assessed using a Pearson Correlation Coefficient and a One-Way ANOVA with Post-Hoc Tukey HSD Analysis. The Nash-Moe +1 Group scored a mean maximal rotation of 14.65° ±6.56 (11.82 – 17.48) (95% Confidence Interval), Nash-Moe +2 mean maximal rotation was 19.6° ±7.1 (16.92 – 22.28) and Nash-Moe +3 scored 21.53° ±8.9 (16.99 – 26.37). The Pearson Correlation Coefficient of this assessment was +0.342 (p value 0.07) demonstrating a weak positive correlation. The One-Way ANOVA analysis with Post-Hoc Tukey HSD analysis. The results of this analysis was an F value score of +4.115 (p Value 0.021) for the overall One-Way ANOVA test. The Post-Hoc Tukey HSD tests demonstrate that there is a statistical difference between Group 1 and Group 3 (p value 0.030) but there is no statistical difference between Group 1 and Group 2 (p value 0.068) as well as no statistical difference between Group 2 and Group 3 (p value 0.716). DIERS Formetric Scan assessment of vertebral rotation shows a positive correlation with the Nash-Moe method. This allows us to rely on the Formetric scans and thus a possible reduction in radiographs when assessing A.I.S, this reduces the exposure to ionising radiation in A.I.S patients.
Right-Handed Girls With Rt-Ais Measured Using Holtain Equipment Have Upper Arm Length Asymmetry (Right-Minus-Left) Which Is: 1) Relatively Longer On Scoliosis Curve Convexity; 2) Significantly Associated With Scoliosis Curve Severity (Cobb Angle And Apical Vertebral Rotation); And 3) Transient, Decreasing With Age And Years After Menarche [1,2]. The Aim Is To Test Whether The Right Upper Arm Length Relative Overgrowth And Spinal Deformity Severity Were Associated With Right Or Left Upper Arm Length Size-For-Age. 94 Right-Handed Girls With Rt-Ais, Age 11–18 Years, (Mean Cobb Angle 46 Degrees, Range 10–102 Degrees), Were Evaluated Using A Harpenden Anthropometer For Upper Arm Length Asymmetry, Plotted Against Right And Left Upper Arm Length Standard Deviation Scores (Sds), Calculated From 378 Normal Girls, Age 11–18 Years.Aim:
Method:
To Determine The Effect Of Posterior Instrumented Fusion On Lung Function In Patients With Idiopathic Scoliosis Aged 8–11. Lung Function (Fvc And Fev1) Was Measured Before Surgery In 13 Patients (Aged 8 To 11) With Idiopathic Scoliosis. All Patients Had Curves Greater Than 50 And Had Undergone Posterior Instrumented Scoliosis Correction And Fusion With (3 Patients) Or Without (10 Patients) Same Day Anterior Convex Growth Arrest. Lung Function Tests Were Repeated 1–8 Years (Mean 5.3 Years) After Surgery. The Data Was Normalised To Take Into Account Standing Height And Loss Of Stature Due To Lateral Curvature, Allowing A Direct Comparison Of Percent Predicted Fev1 And Fvc Before And After Surgery.Aim:
Method:
The primary aim of the study was to test the feasibility of conducting a full RCT with economic analysis and help to inform the provision of physiotherapy in a specific sub-group of patients with sciatica 60 patients waiting for primary, unilateral, single level, lumbar micro-discectomy surgery were recruited and randomised into two groups. The intervention group received a new spinal physiotherapy regimen. Primary outcome measure was the number of patients who did not require surgery at the time of consent clinic. Secondary measures were the Visual Analogue Scale (VAS) Oswestry Disability Index (ODI) and EQ5DL, taken at recruitment, 1 week before surgery and 2 weeks and 3 months after surgery.Purpose of study and background
Methods
To investigate the views and experiences of patients with sciatica who have undergone a bespoke physiotherapy programme whilst awaiting primary lumbar microdiscectomy. This is a qualitative study, nested within a preliminary RCT. All patients were listed for primary, single-level microdiscectomy surgery. In the experimental arm of the study 29 patients had up to 6 sessions of physiotherapy over an 8 week period while on the waiting list for lumbar microdiscectomy. After surgery, they were invited to participate in an in-depth semi-structured interview. At this time patients had either decided not to have the surgery, or had undergone surgery. Interviews were audio-recorded, transcribed, and thematically analysed. Two researchers were involved in the analysis of the data to ensure the interpretation of the findings was robust, credible and trustworhy.Objectives
Methods
Spinal infections constitute a spectrum of disease comprising pyogenic, tuberculous, nonpyogenic-nontuberculous and postoperative spinal infections. The aim of this study was to review the epidemiology, diagnostic yield of first and second biopsy procedures and microbiology trends from Sheffield Spinal Infection Database along with analysing prognostic predictors in spinal infections. Sheffield Spinal Infection Database collects data prospectively from regularly held Spinal infection MDTs. We accrued 125 spinal infections between September 2008 and October 2010. The medical records, blood results, radiology and bacteriology results of all patients identified were reviewed. In patients with negative first biopsy, second biopsy is contemplated and parenteral broad spectrum antibiotic treatment initiated.Introduction
Materials and Methods
To question the reliability of Thoracic Spine pain as a red flag and symptoms of a possible cause of Serious Spinal Pathology (SSP). The clinical notes and Magnetic Resonance Imaging (MRI) results of patients presenting to the Sheffield Spinal Service with Thoracic spine symptoms but no signs were retrospectively reviewed over the period of 2 year (September 2008-August 2010). The clinical reason for request of Thoracic MRIs were noted and the patient notes were reviewed to determine their presentation, length of time of symptoms, age and also it was noted whether any other recognized red flag symptoms were present. Exclusion criteria consisted of patients referred with known SSP or myelopathic symptoms.Purpose
Methods
To evaluate the competencies of spinal extended scope physiotherapists (ESP) following the introduction of requesting rights for magnetic resonance imaging (MRI) one year later. From September 2009 to August 2010 each MRI scan requested by the 2 spinal ESPs within the orthopaedic clinic was recorded along with their clinical diagnosis to ascertain why the scan was requested. This was indicated on a four point scale of likelihood of pathology which had been introduced to give evidence for MRI requesting rights. This was then audited to determine the total number of scans requested along with the accuracy or justification of the request.Purpose
Methods
In patients with adolescent idiopathic scoliosis (AIS), anomalous extra-spinal left-right skeletal length asymmetries in upper limbs, periapical ribs, and ilia beg the question as to whether these bilateral asymmetries are connected in some way with pathogenesis. The upper arm and iliac length asymmetries correlate significantly with adjacent spinal curve severity respectively in thoracic and lower (thoracolumbar and lumbar) spine. In lower limbs, skeletal length asymmetries and proximo-distal disproportion are unrelated to spinal curve severity. Overall, these observations raise questions about mechanisms that determine skeletal bilateral symmetry of vertebrates in health and disorder, and whether such mechanisms are involved in the cause of this disease. We investigated upper arm length (UAL) asymmetries in two groups of right-handed girls aged 11–18 years, with right thoracic adolescent idiopathic scoliosis (RT-AIS, n=98) from preoperative and screening referrals (mean Cobb angle 45°) and healthy controls (n=240). Right and left UAL were measured with a Harpenden anthropometer of the Holtain equipment, by one of four observers (RGB, AAC, RKP, FJP). UAL asymmetry was calculated as UAL difference, right minus left, in mm. Repeatability of the measurements was assessed by technical error of the measurement (TEM) and coefficient of reliability (R).Introduction
Methods
Medical Exposure Directive of the European Commission, 97/43/Euratom recommended setting-up local national diagnostic reference levels (DRLs) for the most common radiological examinations in order to comply with the law and to maintain safe clinical practice. There are no guidelines for spinal diagnostic and therapeutic procedures. The aims of this study were to evaluate local radiation doses & screening times for diagnostic spinal blocks, to look at PACS image intensifier films for diagnostic representation and to assess the accuracy of data in IR(ME) document. Between 1/01/2009 and 15/07/2010, all spinal blocks done under care of three spinal surgeons (LB/NC/AAC) were reviewed. Images revisited on PACS for confirmation. We reviewed 229 patients (included single & two levels nerve root blocks, facet joint and lysis blocks). Data were collected with regard to radiation dose, screening times, third-quartile values used to establish DRLs, IR(ME) documentation and PACS fluoroscopic image documentation.Introduction
Materials and Methods
