Pain management has remained a challenge for surgeons since the dawn of organised medicine. A massive influx of unproven techniques and alternative therapies has descended upon us with little regard to true efficacy and even safety. It is incumbent upon us as practitioners of medicine to finally begin to pay more attention to the tenets of evidenced based medicine while making therapeutic choices.

Johns Hopkins has had a long history of dealing with pain in many of its chameleon forms ranging from the management of acute post-operative pain to the more difficult management of chronic pain. To effectively manage pain in a surgical practice requires attention to first establishing the type of pain (ie. nociceptive or neuropathic). Once the type of pain is clear, specific algorithms can be worked out based on the principles of evidenced based medicine which can be carried out by a variety of paramedical personnel (ie. Physician Assistants or Nurses) without specific surgeon input. This maximises benefit to the patient and minimises problems for the surgeon. Specific algorithms for the management of acute LBP, chronic LBP, acute postoperative pain, chronic postoperative pain, cancer pain and sociopathic pain will be discussed.

Introduction: Anterior lumbar interbody fusion has become a frequently utilised procedure. The trend has been towards less invasive techniques including laparascopic and mini-open techniques. This report examines the results of one procedure and suggests appropriate tools to decrease the learning curve.

Methods: Twenty-two patients with a mean age of 41 (17–78) underwent mini-open ALIF with threaded cortical bone dowels. The same senior surgeon performed all procedures (RFD). Indication for the procedure was discogenic pain verified by concordant discography after a failure of a minimum of six months non-operative treatment. Patients were followed at standard intervals. Complications as well as the evolution of surgical technique were recorded prospectively for all patients.

Results: Twenty-one of 22 patients had the successful implantation of two dowels at each level. Intraoperative fluoroscopy and auditory EMG monitoring was used in all cases. Thirty-two levels were fused from L2–S1 (Average =1.39 levels). Average length of stay was 2.96 days (1–14). Follow-up averaged 24.93 months (2–36). Fusion was achieved in 15/16(93%) of the one level cases but only 3/6 (50%) of the two level cases. Posterior reoperation with posterolateral fusion and pedicle screws was performed in 2/3 of these patients. Use of a dedicated pin-based anterior lumbar retractor enabled a 45% reduction in incision length with a 40% decrease in operative time. Complications included: massive bleeding (1), post-operative dysesthetic leg pain (2), postoperative kyphosis (2), lateral graft displacement (1).

Discussion and conclusion: ALIF remains a formidable surgical procedure. Precise identification of the midline and use of fluoroscopy assures good placement of the devices. Preoperative osteopenia should be recognised and treated with posterior stabilisation. Posterior stenosis should be a relative contraindication. We have abandoned multilevel standalone procedures given the poor fusion rate. A pin-based retractor allows a smaller incision with less operative time. Attention to myriad technical details remains paramount.

Introduction: Although anterior cervical discectomy and fusion is a well-established technique for arthrodesis of the cervical spine, there are limited data on the use of allograft with plate in large series. There are even fewer such studies that incorporate three and four level fusions. We report our experience with 252 patients (530 levels).

Methods: 252 patients underwent anterior cervical discectomy and fusion (ACDF) with plate and allograft (91-one level, 74-two levels, 57-three levels, 30-four levels; 530 total levels) via a modified Smith-Robinson technique. Radiographic fusion was determined with plain X-rays at predetermined intervals. Fusion was defined as no lucent line and no hardware failure. Average follow-up was 22.5 months. Average age was 50 years (M 26, F 19). Comorbidities included 58 smokers and 16 diabetics. Patients wore an external orthosis for six weeks.

Results: There were six reoperations for junctional disease outside the original fusion construct. 16 patient developed junctional disease. 28 levels had residual radiographic lucent lines and/or hardware failure at most recent follow-up for a fusion rate of 94.7% (502/530). Complications occurred in 32 patients (6.0%). There included 16 instances of hardware failure and/or pseudoarthrosis, nine of which occurred in the three and four level group, dysphagia (9), vocal cord dysfunction (2), respiratory distress (2), wound hematoma (2), wound infection (1).

Conclusion/discussion: Extremely high fusion rates were recorded in this series, including three and four level constructs, with an acceptable complication rate. We believe that outstanding results are obtainable with allograft and plate, even at three or four levels. The principles of precise fit and fill of the interspace with a contoured graft and fixation with compression and instrumentation must be employed.

Technology has grown at a logarithmic pace during the last century. The ability to accommodate these challenges in today’s operating theatre has become problematic. A specific task force has been established at Johns Hopkins to deal with these issues proactively.

The operating room of the future must be able to integrate technology with continuous attention to modern day economics. Contributions from surgical staff must be combined with input from administrators, architects, and industry. Physician surgical administrators are perhaps the best compromise to spearhead such projects.

I will introduce the concepts of interstitial space, imaging track systems and surgical workstations to stimulate thought and discussion.