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
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:
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
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
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
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.
We do know that the use of stand-alone cage with no plate is prone to subsidence and segmental kyphosis. Cage and plate construct are prone to adjacent level ossification. Zero P (Synthes, UK) cage combines the functionality of spacer and anterior plate. Radiological evaluation of subsidence of cervical spine after anterior cervical interbody fusion using Zero P cage system. Method: Retrospective review of radiographic records of patients undergoing surgery between June 2008- Oct 2009. We evaluated lateral cervical standing radiographs before, after, 6 weeks, 3, 6 months of surgery. We measured subsidence (using Total Intervertebral Height (TIH). All measurements were done using Web 1000 (Impax Agfa). Two level was treated as single segment. Subsidence > 3mm was considered significant. 20 patients (11 male: 9 female) with median age of 51 yrs (40-65) underwent one (n=10) or two level (n= 10) cervical fusion. Immediately post-op there was increase in TIH in one and two level group by 1.74mm (1.61 and 4.25mm (1.48 respectively, which at 6 months reduced to 1.05mm (0.24 (p< 0.003) and 1.32mm (1.29 (p< 0.085) at 6 months respectively. Subsidence was seen in all cases and was rapid in first 3 months and then tailed off. It was significant (> 3mm) only in 2/20 (2%) patients at 6 months. Early results indicate that spine alignment is maintained radiologically with no associated complications as screw loosening, cage extrusion etc.
Spinal cord injury following trauma is initially dealt with by acute hospitals. The early management including stabilization is usually performed by these centres. This is followed by onward referral to one of the Regional Spinal Injury Units. There is concern of both sides of the fence regarding mobilization following spinal cord injury. The acute hospitals want to avoid the problems of prolonged recumbency and the Regional Spinal Injury Units wish to avoid the problems of early aggressive mobilization. Therefore, we set out to discover if there was a standard approach to mobilising these patients following surgical stabilization, because of the oversubscribed resources of the spinal injury units and the wish to start mobilizing the injured as soon as possible. A comparative audit of the Regional Spinal Injury Units in the UK and North American Units. Regional Spinal Injury Units in United Kingdom and North America Clear Management Plan Mobilisation Schedule We had replies from all Regional Spinal Injury Units in the UK and from seven in North America. The Regional Spinal Injury Units all had differing approaches. Only a few were able to convey a clear management plan and mobilization schedule. Whereas the North American Units provided a ‘mobilize as able’ plan in all cases. The North American Units had a ‘mobilize as able’ policy, whereas the UK units had a mixed approach. A coherent collaboration between the spinal surgeons stabilizing these injuries and the spinal injury units providing rehabilitation would improve patient management.
To evaluate Radiological changes in the lumbosacral spine after insertion of Wallis Ligament for Foraminal Stenosis. Thirty two Levels in Twenty Six patients were followed up with standardised radiographs after insertion of Wallis Ligaments for Foraminal Stenosis. Wallis ligaments as a top-off or those with prolapsed discs were not included. The Radiological parameters compared were Anterior and Posterior Disc height, Foraminal height and width, The inter-vertebral angle (IVA), Lumbar lordosis and Scoliosis if any. The presence of slips and their progression post-op was noted, as was bony lysis if any. There were ten males with thirteen levels and sixteen females with nineteen levels in the study. Eighteen levels (56.25%) were L4/L5, ten (31.25%) were L5/S1 and 4 (12.5%)were L3/L4. The average age in the series was 59.6 years (Range 37 – 89 yrs). Average follow up was 9.5 months (Range 2 to 36). The Average increase in Anterior disc height was 1.89 mm (+/−1.39), the posterior disc height increased by an average 1.09 mm (+/−1.14). Foraminal height increased by an average 3.85 mm (+/− 2.72), while foraminal width increased by 2.14 mm (+/− 1.38). The IVA increased in 16 and reduced in 15 patients, with no change in 1. Lumbar Lordosis increased in 23 patients, with an average value of 2.3°. No patient exhibited progression in scoliosis and no lysis could be identified. There were three Grade I slips pre-op; none progressed. Foraminal dimensions and Disc height were consistently improved after Wallis insertion. Changes in IVA and Lumbar lordosis were however variable. A longer follow up is suggested to look for sustained improvement and the presence of lysis.
Spinal Biomechanics Lab, Baylor College of Medicine, Houston, Texas, USA Documenting the patterns and frequency of collapse in non-operatively managed spine fractures, using a motion analysis software. Retrospective analysis of prospective case series 105 patients with thoracic or lumbar fractures, were neurologically intact, and treated non-operatively for the ‘stable’ injury at our unit between June 2003 and May 2006. The mean age of the cohort was 46.9 yrs Serial radiographs (mean 4 radiographs/patient; range 2 – 9) were analysed using motion analysis software for collapse at the fracture site. We defined collapse as a reduction of anterior or posterior vertebral body height greater than 15% of the endplate AP width, or a change in the angle between the inferior and superior endplates > 5°. The changes were assessed on serial radiographs performed at a mean of 5.6 mo (95% CI 4.1 – 7.1 mo) after the initial injury. 11% showed anterior collapse, 7.6% had posterior collapse, 14% had collapse apparent as vertebral body wedging, and 17% had any form of collapse. ODI scores were obtained in 35 patients at the time of the last available radiograph. There were no significant differences in ODI scores that could be associated with the presence of any form of collapse (p > 0.8 for anterior collapse; and p = 0.18 for posterior collapse). This pilot study with the motion analysis software demonstrates that some fractures are more likely to collapse with time. We hope to carry this work forward by way of a prospective study with a control on other variables that are likely to affect the pattern and probability of post-fracture collapse, including age, bone density, vertebral level, activity level, fracture type.
Our study aims to evaluate the efficacy of Wallis implant in management of discogenic back pain. We have prospectively studied thirty patients between 2006 and 2007. Average age of patients was 40.8 years. Average follow-up period 20.6 months (9-28). Main inclusion criteria includes failure of conservative management of low back pain due to degenerative disc disease, preservation of 50% of the disc height and positive discographic features. In majority of the patients the implant was put in at the level of L4-L5. Pre-op and post op SF36 and Oswestry Disability Index (ODI) scores were assessed during clinic follow-up and by telephonic interview. Mean SF36 score improved from thirty-seven (8.3 – 54.3) to 51.4. Mean ODI improved from forty-three (20-60) to 26.5(2-60) (p = 0.026). Complications including superficial infection occurred in one patient, deep infection in one patient, erosion of spinous process in one and displacement of the implant in one case. Three (10%) patients had revision surgery due to various reasons. Wallis interspinous dynamic stabilization system could be used as a soft stabilisation device avoiding fusion and short-term results are promising. In selected group of discogenic low back pain patients it is a useful interim procedure. Long-term follow-up of our series is ongoing.
