7% of adolescent idiopathic scoliosis (AIS) patients also present with a pars defect. To date, there are no available data on the results of fusion ending proximal to a spondylolysis in the setting of AIS. The aim of this study was to analyze the outcomes of posterior spinal fusion (PSF) in this patient cohort, to investigate if maintaining the lytic segment unfused represents a safe option.

Retrospective review of all patients who received PSF for AIS, presented with a spondylolysis or spondylolisthesis and had a min. 2-years follow-up. Demographic data, instrumented levels and preoperative radiographic data were collected. Mechanical complications, coronal or sagittal parameters, amount of slippage and pain levels were evaluated.

Data from 22 patients were available (age 14.4 ± 2.5 years), 18 Lenke 1–2 and four Lenke 3–6. Five patients (24%) had an isthmic spondylolisthesis, all Meyerding I. The mean preoperative Cobb angle of the instrumented curves was 58 ± 13°. For 18 patients the lowest instrumented vertebra (LIV) was the last touched vertebra (LTV); for two LIV was distal to the LTV; for two, LIV was one level proximal to the LTV. The number of segments between the LIV and the lytic vertebra ranged from 1 to 6. At the last follow-up, no complications were observed. The residual curve below the instrumentation measured 8.5 ± 6.4°, the lordosis below the instrumented levels was 51.4 ± 13°. The magnitude of the isthmic spondylolisthesis remained constant for all included patients. Three patients reported minimal occasional low back pain.

The LTV can be safely used as LIV when performing PSF for the management of AIS in patients with L5 spondylolysis

The purpose of this study is to evaluate risk factors for distal construct failure (DCF) in posterior spinal instrumented fusion (PSIF) in adolescent idiopathic scoliosis (AIS). We observed an increased rate of DCF when the pedicle screw in the lowest instrumented vertebra (LIV) was not parallel to the superior endplate of the LIV, however this has not been well studied in the literature. We hypothesise a more inferiorly angled LIV screw predisposes to failure and aim to find the critical angle that predisposes to failure.

A retrospective cohort study was performed on all patients who underwent PSIF for AIS at the Starship Hospital spine unit from 2010 to 2020. On a lateral radiograph, the angle between the superior endplate of the LIV was measured against its pedicle screw trajectory. Data on demographics, Cobb angle, Lenke classification, instrumentation density, rod protrusion from the most inferior screw, implants and reasons for revision were collected.

Of 256 patients, 10.9% (28) required at least one revision. The rate of DCF was 4.6% of all cases (12 of 260) and 25.7% of revisions were due to DCF. The mean trajectory angle of DCF patients compared to all others was 13.3° (95%CI 9.2° to 17.4°) vs 7.6° (7° to 8.2°), p=0.0002. The critical angle established is 11°, p=0.0076. Lenke 5 and C curves, lower preoperative Cobb angle, titanium only rod constructs and one surgeon had higher failure rates than their counterparts. 9.6% of rods protruding less than 3mm from its distal screw disengaged.

We conclude excessive inferior trajectory of the LIV screw increases the rate of DCF and a screw trajectory greater than 11° predisposes to failure. This is one factor that can be controlled by the surgeon intraoperatively and by avoiding malposition of the LIV screw, a quarter of revisions can potentially be eliminated.

Study Design: To design and test a new questionnaire to assess depression and other mood states.

Summary of Background Data: Measurement of depression and of other mood states in pain patients has been criticised in recent years on the grounds that most questionnaires were not developed in pain populations and suffer from criterion contamination by somatic items. In addition, there is no accepted measurement for positive emotions which are more than the absence of depression.

Objective: To develop a reliable and brief tool to assess mood in pain patients.

Method: Non-somatic items concerning depression, anxiety and positive outlook were extracted using exploratory factor analysis from commonly used instruments (Beck Depression Inventory and Hospital Anxiety and Depression Scale) completed by over 900 chronic pain patients. Confirmatory factor analysis was used to test the internal structure of the final item set. Items were then reworded and presented as a new questionnaire (the Depression, Anxiety and Positive Outlook Scale: DAPOS) to two new samples: patients attending pain management and patients attending osteopathy. The new questionnaire was compared with several well-known questionnaires (SF-36, BDI, PCS). The structure was calibrated and tested using confirmatory factor analysis on both samples. Finally, a sub-set of patients carried out a sorting task to test for face validity.

Results and conclusion: The DAPOS performed well, indicating that it is a reliable measure of the three mood states with good initial evidence of validity in these samples.

Purpose and Background: Despite widespread clinical belief, a previous systematic review found insufficient evidence to substantiate fear avoidance beliefs (FAB) as a risk factor for long-term problems in low back pain. This updated review explores whether there is stronger evidence supporting the role of fear avoidance in early stages of low back pain as a predictor of outcome. In addition, this evidence was examined in reference to current models and knowledge about fear avoidance.

Methods and Results: A systematic literature search for all prospective inception cohorts of low back pain that included psychological factors at baseline between 2000 and 2003 was made. We searched MEDLINE, psychINFO, AMED, CINAHL, Social Science Citation Index, Science Citation Index databases. Included studies had early recruitment of up to three weeks since onset of back pain and an absence of back pain in the previous three months. These studies were coded according to criteria adapted from Pincus et al (2002) blindly by two researchers. A sample of these was coded by a third blinded reviewer. An independent statistician performed statistical conversion of reported results to effect sizes. Out of the six included studies, four included valid and reliable measures of fear avoidance. There was only weak evidence implicating fear avoidance as a predictor of disadvantageous outcome.

Conclusions: There is insufficient evidence to support or refute the basic concept of fear avoidance as a risk factor for poor outcomes in low back pain. Experimental studies indicate that those with high FAB benefit from targeted intervention. To explain this we propose a model of FAB containing two distinct groups.

The aim of the study was to assess the outcome of fractures of the fifth metacarpal neck and to develop an accurate method of assessing fracture angulation.

Forty-two patients who were available for review were assessed using a patient questionnaire, assessing range of movement, cosmesis, pain and strength. A trigonometric method of determining true fracture angulation from AP and oblique radiographs was developed. There were 36 males and 6 females with an average age of 23.4 years, with a minimum follow up of 12 months. Patients with fractures angulated more than 45 degrees in whom reduction was not performed had a significantly lower score for grip strength and function. 32 patients reported a mild cosmetic deformity. The method of reduction and the method and duration of immobilisation did not correlate with the final outcome. A phantom was constructed that confirmed the accuracy of the method of calculating true fracture angulation from the oblique radiographs.

Fractures of the fifth metacarpal neck if not reduced to a true angulation of less than 45 degrees produce an unsatisfactory outcome. A method of assessing true angulation has been developed.

Study design: A systematic review of prospective cohort studies in low back pain.

Objectives: To evaluate the evidence implicating psychological factors in the development of chronicity in low back pain.

Summary of background: The biopsychosocial model is gaining acceptance in low back pain, and has provided a basis for screening measurements, guidelines and interventions. However, to date, the unique contribution of psychological factors in the transition from an acute presentation to chronicity has not been rigorously assessed.

Methods: A systematic literature search was followed by the application of three sets of criteria to each study: methodological quality, quality of measurement of psychological factors, and quality of statistical analysis. Two reviewers blindly coded each study, followed by independent assessment by a statistician. Studies were divided into three environments: primary care, pain clinics and workplace-based studies.

Results: Twenty-five publications (18 cohorts) included psychological factors at baseline. Six of these met acceptability criteria for methodology, psychological measurement and statistical analysis. Increased risk of chronicity (persisting symptoms and/or disability) from depressive mood and, to a lesser extent, somatisation emerged as the main findings. Acceptable evidence generally was not found for other psychological factors, although weak support emerged for the role of catastrophising as a coping strategy.

Conclusions: Both depressive mood and somatisation are implicated in the transition to chronic low back pain. The development and testing of clinical interventions specifically targeting these factors is indicated. In view of the importance attributed to other psychological factors, there is a need to clarify their role in back-related disability through rigorous prospective studies.