Laminar flow theatres were first introduced in the United Kingdom in the 1960s and 1970s and have become standard in orthopaedic surgery involving implants. A study from 1982 showed a 50% reduction in infections with joint arthroplasties when compared to conventional theatres and laminar flow became standard in the following decades. Recent evidence including a meta-analysis from 2017 questions the effectiveness of these theatre systems. Most of the evidence for Laminar flow use is based on arthroplasty surgery. We aimed to determine the effect of using non-laminar flow theatres on our trauma patients. A total of 1809 patients who had trauma surgery were identified from 2019 to 2021. 917 patients were operated on in a laminar theatre and 892 in a non-laminar theatre across two operating sites. We identified the surgical site infections as reported through our surveillance program within the first 90 days of infection. Patient co-morbidities were noted through patient records and procedure length was also noted. Of the 1809 trauma patients identified between the years of 2019 and 2021, 917 patients had operations in a laminar flow theatre and 892 in a non-laminar theatre. Of the 892 operated in non-laminar flow theatres, 543 were operated in the University Hospital of Wales (UHW) and 349 at the University Hospital of Llandough (UHL). An analysis of soft tissue infections and hospital acquired infections post-operatively demonstrated 15/543 and 71/543 respectively for non-laminar UHW infections and 4/349 and 21/349 for non-laminar UHL infections. A look at laminar flow patients showed 25/917 with soft tissue infections and 86/917 hospital acquired infections. There was no difference between laminar and non-laminar flow theatre infection rates showing rates of 12.1% and 12.2% respectively. In our trauma patients we noticed no significant advantage of using laminar flow theatres when compared to non-laminar flow theatres. This is in keeping with some recently published literature. Laminar flow theatres have been shown to decrease airborne pathogen counts under controlled conditions, but we conclude in the day to day environment of trauma theatres these conditions are either not met or that the theoretical advantage of laminar flow does not translate to a direct advantage of reduction of infections which may be achieved by standard prophylactic antibiotics.
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
With resumption of elective spine surgery services following the first wave of COVID-19 pandemic, we conducted a multi-centre BASS collaborative study to examine the clinical outcomes of surgeries. Prospective data was collected from eight spinal centres in the first month of operating following restoration of elective spine surgery following the first wave. Primary outcomes measures were the 30-day mortality rate and postoperative Covid-19 infection rate. Secondary outcomes analysed were the surgical, medical adverse events and length of inpatient stay.Abstract
Aim
Methods
University Hospital of Wales (UHW) went live as a Major Trauma Centre (MTC) on the 14th September 2020. New guidelines have been set up by the Wales Trauma Network. Prospective audit to see how many admissions, correct pathways were followed?Abstract
Background
Aim
Cauda equina syndrome (CES) is a rare serious condition that, if missed at initial presentation, can lead to serious disability. Early diagnosis is crucial for a favourable outcome. Few studies included urodynamic test and measurement of post-void residual urine (PVR) as an adjunct screening tool for acute CES before proceeding to MRI scan, yet there are differences in the cut-off point as a threshold volume to be considered as a red flag for doing MRI amongst these studies. Meta-analysis and systematic review of literature that included PVR as a predictive tool in CES to identify the reliability of PVR and the optimal numerical value to be considered as red flag.Abstract
Background
Aim
To determine the efficacy and safety of the Magec system in early onset scoliosis (EOS). In 2011, 6 males and 2 females had Magec rods, with an average age of 8.5 years (2.9–12.7 years), 7 patients had dual rods, and 1 had single. The main cause of EOS was idiopathic scoliosis (n=6), followed by Congenital (n=1), and Syndromic (n=1). Average follow up was 19.4 months (14–26 months). 4 of these patients had their previous Paediatric Isola growing rods exchanged to Magec, and 1 patient had an exchange from single to Dual Magec rods.Aim:
Methods:
To measure truncal parameters for patients treated with growing rod systems for early onset scoliosis (EOS). 44 patients underwent growth rod surgery for EOS between 1999 and 2013 (24 females and 20 males). 27 patients had idiopathic scoliosis, 13 congenital, 3 syndromic and 1 neuromuscular. 26 patients had Paediatric Isola, 8 had Paediatric Expedium, 4 had dual growth rods with domino's and 9 each had VEPTR and MAGEC rods systems. Medical records and radiographs were analysed. Cobb angle, T1-T12 and T1-S1 length, coronal and sagittal balance, apical vertical translation (AVT), space available for the lung (SAL) and shoulder balance were measured.Aim:
Methods:
Assessing the efficacy of cervical orthoses in restricting spinal motion has historically proved challenging due to a poor understanding of spinal kinematics and the difficulty in accurately measuring spinal motion. This study is the first to use an 8 camera optoelectronic, passive marker, motion analysis system with a novel marker protocol to compare the effectiveness of the Aspen, Aspen Vista, Philadelphia, Miami-J and Miami-J Advanced collars. Restriction of cervical spine motion was assessed for physiological and functional range of motion (ROM). Nineteen healthy volunteers (12 female, 7 male) were fitted with collars by an approved physiotherapist. ProReflex (Qualisys, Sweden) infra-red cameras were used to track the movement of retro-reflective marker clusters attached to the head and trunk. 3-D kinematic data was collected from uncollared and collared subjects during forward flexion, extension, lateral bending and axial rotation for physiological ROM and during five activities of daily living (ADLs). ROM in the three clinical planes was analysed using the Qualisys Track Manager (Qualisys, Sweden) 6 Degree of Freedom calculation to determine head orientation relative to the trunk. For physiological ROM, the Aspen and Philadelphia were more effective at restricting flexion/extension than the Vista (p<0.001), Miami-J (p<0.001 and p<0.01) and Miami-J Advanced (p<0.01 and p<0.05). The Aspen was more effective at restricting rotation compared to the Vista (p<0.001) and Miami-J (p<0.05). The Vista was least effective at restricting lateral bending (p<0.001). Through functional ROM, the Vista was less effective than the Aspen (p<0.001) and other collars (p<0.01) at restricting flexion/extension. The Aspen and Miami-J Advanced were more effective at restricting rotation than the Vista (p<0.01 and p<0.05) and Miami-J (p<0.05). All the collars were comparable when restricting lateral bending. The Aspen is superior to, and the Aspen Vista inferior to, the other collars at restricting cervical spine motion through physiological ROM. Functional ROM observed during ADLs are less than those observed through physiological ROM. The Aspen Vista is inferior to the other collars at restricting motion through functional ROM. The Aspen collar again performs well, particularly at restricting rotation, but is otherwise comparable to the other collars at restricting motion through functional ranges.
The aim of the study was to highlight the absence of an important pitfall in the Advanced Trauma Life Support protocol in application of rigid collar to patients with potentially unstable cervical spine injury. We present a case series of two patients with ankylosed cervical spines who developed neurological complications following application of rigid collar for cervical spine injuries as per the ATLS protocol. This has been followed up with a survey of A&E and T&O doctors who regularly apply cervical collars for suspected unstable cervical spine injuries. The survey was conducted telephonically using a standard questionnaire. 75 doctors completed the questionnaire. A&E doctors = 42, T&O = 33. Junior grade = 38, middle grade = 37. Trauma management frontline experience >1yr = 50, <1yr = 25. Of the 75 respondents 68/75 (90.6%) would follow the ATLS protocol in applying rigid collar in potentially unstable cervical spine injuries. 58/75 (77.3%) would clinically assess the patient prior to applying collar. Only 43/75 (57.3%) thought the patients relevant past medical history would influence collar application. Respondents were asked whether they were aware of any pitfalls to rigid collar application in suspected neck injuries. 34/75 (45.3%) stated that they were NOT aware of pitfalls. The lack of awareness was even higher 17/25 (68%) amongst doctors with less that 12 months frontline experience. When directly asked whether ankylosing spondylitis should be regarded as a pitfall then only 43/75 (57.3%) answered in the affirmative. We would like to emphasise the disastrous consequences of applying a rigid collar in patients with ankylosed cervical spine. The survey demonstrates the lack of awareness (∼ 50%) amongst A&E and T&O doctors regarding pitfalls to collar application. We recommend the ATLS manual highlight a pitfall for application of rigid collars in patients with ankylosed spines and suspected cervical spine injuries.
The British Scoliosis Society published a document in 2008 which set out the minimum standards for paediatric spinal deformity services to achieve over a period of time. But how do the UK paediatric spinal deformity centres measure up to these benchmarks? We performed a telephonic survey, contacting every UK spinal deformity centre. The questionnaire probed how each unit compared to the recommended standards.Introduction
Methods
Comparison between Aprotinin and Tranexamic acid on blood conservation in scoliosis surgery. There is no difference in the control of blood loss between 2 drugs.Purpose
Null hypothesis
Retrospective review of growth sparing spinal instrumentation. Medical records of 30 children with spinal deformity treated were evaluated. There were 14 male and 16 female patients at an average age of 4.9 years (1-14) at the time of presentation. These included 18 idiopathic, 11 congenital and a 14 year old with delayed growth having GH treatment. All patients underwent dual growing rod construct using hook and pedicle screw instrumentation. Extensions were carried out at approximately 6 monthly intervals. Average follow up was 4.2 years (2-8.5) with an average of 7.3(3-15) extension/exchange procedures per patient. Average immediate postoperative Cobb angle was 29(15-55) from a preoperative Cobb of 68(55-100) and this was maintained to a final mean Cobb angle of 30(15-60). Average gain in T1-S1 length was 5.7(3.5-9.8) cm. Five patients had final fusion at an average age of 15.5 years. There were no infections following primary operation. Out of 249 procedures including extensions/exchange, there were 9(4.5%) episodes of deep infection in 7 patients requiring debridement. Four patients (13%) had revisions for rod breakage/screw loosening/hook pullout/junctional kyphosis and three(10%) had prominent implants.Purpose
Methods and results
To evaluate efficacy of blood conservation strategies on transfusion requirements in adult scoliosis surgery and establish a protocol for cross matching. Retrospective review of 50 consecutive adult scoliosis patients treated using anterior only(14,28%), posterior only(19,38%) or combined(17,34%) approaches. All patients were anaesthetised by the same anaesthetist implementing a standard protocol using cell salvage, controlled hypotension and antifibrinolytics. Mean age was 24.6 years. BMI was 21.9. On an average 9.5(6-15) levels were fused, with an average duration of surgery of 284.6(130-550) minutes. Antifibrinolytics were used in 31(62%) of the patients which included Aprotinin in 21(42%) and Tranexamic acid in 10(20%). Patients on antifibrinolytics had a significantly (p<0.05) lower blood loss (530ml) as compared to other patients (672ml). Mean volume of the cell saved blood re-transfused was 693.8 ml and mean postoperative HB level dropped to 10.7 g/dl(7.7-15) from a mean preoperative of 13.3 g/dl(10-17). 7(42%) with combined approaches and 3(15.8%) with posterior only approach required blood transfusion, 4/50(8%) of which required intra while 6/50(12%) required intra and postoperative transfusion. None of the patients having anterior surgery alone required blood transfusion.Purpose
Methods and Results
To compare the effectiveness of the Aspen, Aspen Vista, Philadelphia, Miami-J and Miami-J Advanced collars at restricting cervical spine movement in the sagittal, coronal and axial planes. Nineteen healthy volunteers (12 female, 7 male) were recruited to the study. Collars were fitted by an approved physiotherapist. Eight ProReflex (Qualisys, Sweden) infra-red cameras were used to track the movement of retro reflective marker clusters placed in predetermined positions on the head and trunk. 3D kinematic data was collected during forward flexion, extension, lateral bending and axial rotation from uncollared and collared subjects. The physiological range of motion in the three planes was analysed using the Qualisys Track Manager system.Objective
Methods
Reported incidence of DVT after spinal surgery ranges from 0-15% and PE 0.5-2.7%. Theoretically, manipulation of the vessels and venous stasis caused by retraction during anterior lumbar inter-body fusion may increase the propensity for thrombosis. The reported incidence of DVT and PE following major abdominal and pelvic surgery are high (up to 23%) and all these patients routinely receive chemical prophylaxis. Should patients undergoing ALIF surgery receive chemical prophylaxis routinely?Introduction
Aim
To investigate current practice of thromboprophylaxis in major UK spinal centres for both trauma and elective surgery, and to asses compliance with NICE guidelines A telephonic survey was carried out which comprised of questions relating to current practice of thromboprophylaxis in major spinal units across the UK. Questions probed practice with regard to trauma versus elective surgery, agents used, timing of prophylaxis, length of treatment and whether practice has changed since the introduction of NICE guidelines.Purpose of Study
Methods
Halo traction, either on bed or with an accompanying vest is used commonly in Spine surgery, in a variety of clinical situations. The pins are inserted into the skull in safe anatomic zones, using wrenches that are either pre-torqued or exhibit a torque gauge to allow measurable torque application. A torque of 6 – 8 inch pounds is considered ideal for optimal pin tightening. Lesser torques may hypothetically lead to pin loosening and pin track infections, while, excessive torques could lead to pin penetration through the skull. To test the accuracy and consistency of different torque wrenches used for Halo pin insertion, using a standardised calibration device.Introduction
Aim
To highlight the absence of an important pitfall in the Advanced Trauma Life Support protocol in application of rigid collar to patients with potentially unstable cervical spine injury. We present a case series of two patients with ankylosed cervical spines who developed neurological complications following application of rigid collar for cervical spine injuries as per the ATLS protocol. This has been followed up with a survey of A&E and T&O doctors who regularly apply cervical collars for suspected unstable cervical spine injuries. The survey was conducted telephonically using a standard questionnaire. 75 doctors completed the questionnaire. A&E doctors = 42, T&O = 33. Junior grade = 38, middle grade = 37. Trauma management frontline experience >1yr = 50, <1yr = 25. Of the 75 respondents 68/75 (90.6%) would follow the ATLS protocol in applying rigid collar in potentially unstable cervical spine injuries. 58/75 (77.3%) would clinically assess the patient prior to applying collar. Only 43/75 (57.3%) thought the patients relevant past medical history would influence collar application. Respondents were asked whether they were aware of any pitfalls to rigid collar application in suspected neck injuries. 34/75 (45.3%) stated that they were NOT aware of pitfalls. The lack of awareness was even higher 17/25 (68%) amongst doctors with less that 12 months frontline experience. When directly asked whether ankylosing spondylitis should be regarded as a pitfall then only 43/75 (57.3%) answered in the affirmative.Aim of Study
Study Method
Incidence of pars defect associated with idiopathic scoliosis has been reported as 6% based on roentgenographic evaluation in previous studies. (Fisk et al, 1978). We aim to present our results in an MRI based study. 224 patients of adolescent idiopathic scoliosis (AIS) who had an MRI scan over a period of three years (2006-2008), performed either as a preoperative investigation or due to other symptoms were reviewed. All MRI scans were reviewed by two experienced musculoskeletal radiology consultants independently. Among 224 patients 13 (5.8%) patients were found to have pars defect. Mean age-group of patients were (19 years, range-11-40). 84.6% (n=11) patients were female and 15.3% patients were male. There was varying severity of curve patterns. We have noted two lumbar/thoraco-lumbar curves (Lenke 5), King Type I-6, King Type II-2 and three King Type III curves. All scoliotic deformities were non-structural. Bilateral pars defect was noted in nine (69%) patients. Previous studies (Fisk et al, 1978; Mau H 1981) have described the incidence of pars defect as approximately 6.2%. Recent studies have emphasized use of MRI to diagnose pars defect based on signal changes in the pedicle (Sairyo et al.). Our study reveals the incidence of pars defect in AIS to be 5.8 % based on MRI diagnosis which does not seem to be different to previous roentgenographic studies.
In major procedures like scoliosis surgery, parents are often asked to sign the consent on behalf of children because of the pretext that minor may have limited understanding and judgement about the procedure. Scoliosis surgery for patients with AIS is mainly indicated for cosmetic or psychological reasons. We audited our practice in the department to collect information on the current consent practices involving the minor patients undergoing scoliosis surgery. We also have conducted a questionnaire survey of the various spinal units in UK to assess their practice in this regard. Forty-two consent forms (28 patients; multiple procedures in some patients) and case notes of patients between 12 and 16 years undergoing scoliosis surgery were reviewed. We have contacted 12 spinal deformity correction units and 11 spinal trauma units across UK over telephone to assess the current consenting practice as well. 9.5% (n=4) patients signed there own consent forms. Except in one case explanation of risks were documented in detail. Except two units (18%) offering the minor patient to sign their consent, parents are usually asked to sign consent on their behalf in majority (10/12) units. Seven out of the twelve spinal units use standard NHS or department of health consent forms. Few units have their own consent form with some alterations or additions. There is no specific age when a child becomes competent to consent to treatment: It depends both on the child and on the seriousness and complexity of the treatment being proposed. However, it is still good practice to encourage competent children to more involved along with their families in decision-making.
