Purpose

Distinguishing between sequestered disc fragments and tumours remains a diagnostic challenge, but one of paramount importance given the surgical management of these two clinical entities varies dramatically.

To quantify the duration of symptoms and the treatment modalities employed prior to surgery in patients undergoing lumbar and cervical nerve root decompression and to assess the evidence of these non-surgical treatments.

Pre- and post operative questionnaires completed by consecutive patients.

514 people undergoing consecutive cervical or lumbar nerve root decompression between March 2007 to October 2009.

Pre-operative severity and duration of pain, functional limitations and treatment received. Post-operative pain severity and change in functional limitations.

Evidence in the literature for efficacy of treatment modalities employed.

Mean duration of pre-operative symptoms was 23 months (range 1 to 360). 91% took regular medication for pain, 83% received one or more physical therapy, 24% received injection therapy.

There was improvement in both pain scores (mean pre-op 7.3; post-op 3.0) and 78% of the commonly reported functional limitations, walking, sleep and work.

We found extremely limited evidence to support the other treatment modalities employed.

Patients spend many months unnecessarily in pain, consuming considerable resources and may suffer significant side effects from ineffective treatment for pain emanating from nerve root compression. Surgical nerve root decompression relieves pain and restores function. Despite this a specialist opinion is often delayed. Early referral for specialist opinion is almost certainly more humane, cost effective, and time-limits the journey on the not so magic roundabout.

We have examined how many and which potential complications (PCs) are recorded on the consent form by a group of consultant surgeons performing common spinal procedures - anterior cervical discectomy and fusion (ACDF) and posterior lumbar discectomy and/or medial facetectomy (PLD).

Email survey

Consultant spinal surgeons performing ACDF and/or PLD practicing in Southwest England

Identification of the PCs each surgeon listed on the consent form for the specified procedures.

There were 23 responses from 28 Consultant surgeons approached. 21 surgeons performed both ACDF and PLD, 2 performed only PLD. Surgeons quoted 5 to 17 (mode 10) PCs for ACDF and 4 to 15 (mode 13) for PLD. These did not necessarily represent the most common or most dangerous PCs recorded in the literature^1,2. Small difference in PCs mentioned by Neurosurgeons and Orthopaedic surgeons was seen (ACDF mode: 12vs10, PLD mode: 12vs13). There was a strong correlation between the number of PCs recorded by surgeons for ACDF and PLD.

We have found a wide variation in consenting practice amongst a group of surgeons performing common spinal operations. Issues of consent are common causes of formal complaints and potential litigation, causing anxiety for both patient and surgeon. A more homogenous consent process, employing objective measures where possible, may help reduce this burden and may be achieved by setting a national standard.

To determine if the term “back pain” has uniform meaning to spinal surgeons.

A survey of specialists attending an international meeting on spinal surgery. Participants were shown 5 schematic pain drawings and then asked to categorize the pain as either back or leg pain.

An international cohort of neurosurgeons, orthopaedic surgeons and trauma surgeons (n=104) attending a European spinal meeting.

67% of participants were orthopaedic surgeons and 22% neurosurgeons. 42% were in full time spinal practice. 50% had been in independent practice for 7 years or more. There was no statistical difference in the responses of neuro- and orthopaedic surgeons (Fisher's test, p>0.05).

The more rostral the pain, the more likely it was to be deemed “back pain”. However, unilateral pain was more likely to be deemed “leg pain” than its bilateral symmetrical equivalent no matter how rostral the distribution. Unilateral mid-lumbar pain was considered “back pain” by 48%, symmetrical bilateral mid-lumbar pain in 87%. Pain in the buttocks was considered “back pain” in 50% whether unilateral or bilateral.

This study demonstrates significant discrepancy in what is considered to be back pain and leg pain by a broad spectrum of spinal surgeons. Back pain and leg pain are often investigated and managed in different ways. This differentiation is difficult to justify until we know the answer to the question, what is back pain?

Aim: To investigate the incidence of headache and facial pain in patients with neck pain and/or brachalgia and determine any potentially causal relationship.

Methods & Results: Sequential patients referred to the spinal clinic for assessment of their cervical spine were asked to shade on pain drawings, the distribution of pain and sensory disturbance which they were experiencing.

The distribution of shading was categorised as head pain (subdivided into face, vertex and occiput) and arm pain. The incidence of head pain and its distribution was analysed along with its relationship to arm pain.

Data collected from patients presenting with thoracolumbar pain over the same period was used as a control.

Of 200 patients presenting to the clinic with cervical problems, 58 had head pain. 50 had occipital pain, 28 had vertex pain and 8 had facial pain. None of the thoracolumbar patients had head pain although 12 had upper limb pain.

Of the 26 cervical patients who had unilateral arm pain & head pain, the head and arm pain were always on the same side.

Conclusion: Head & facial pain in association with neck pain and brachalgia is common. The homolaterality of symptoms suggest the potential for causal relationships hitherto unrecognised in the literature. It is possible that some patients given medical diagnoses for their headache (e.g. migraine) might have surgically treatable cervical pathology. Clearly, further investigation to elucidate this potential relationship is required.

Purpose: To determine if the short term benefits we reported from X STOP implants for lumbar radiculopathy were maintained at 2 yr follow up

Methods and Results: We followed all patients, of one neurosurgeon (TG), having XSTOP implants to treatment lumbar radiculopathy secondary to foraminal stenosis. We measured patient-reported pain and disability outcomes (Oswestry disability index, ODI; Short Form 36 bodily pain scale, SF-36 BP) immediately pre-op and approximately 2 years post op. Changes were examined in terms of statistical significance (Wilcoxon signed ranks test) and clinical significance (effect sizes – mean change divided by SD change).

2 yr follow up data were available for 13 of the 15 people who had the surgery. One had died of an unrelated condition before follow up, the other had further lumbar surgery thus affecting the interpretation of the data. Mean duration of follow up was 30.5 months.

Both ODI and SF-36 BP detected sustained improvements 2 yrs after surgery. Results for both scales were statistically significant (z = −3.059 & −3.062; p = 0.002). Mean change scores for both scales were substantial (ODI = 31.7; SF36 BP = 47.4), and effect sizes were very large (ODI = 1.35; SF-36 BP = 1.37) indicating clinically significant improvement. There have been no complications.

Conclusions: These provisional data, albeit from a small sample, provide increasing evidence to imply that the X STOP procedure may suit people with radiculopathy secondary to foraminal stenosis. Moreover, it has been safe and does not jeopardise future surgery in the event of failure.

Ethics approval: None, Audit

Interest Statement: None

Aims

to determine what aspects of people’s lives (domains of impact) where most affected by their spinal problems,

Methods & Results: Data was collected prospectively. New patients attending the spinal clinic completed a questionnaire about their symptoms. They were also asked to list, in order of importance to them, the 3 aspects of their daily life most affected by their symptoms. Responses were in free text format, summarised with the most appropriate single word response (e.g. walking) and grouped. Thoraco-lumbar and cervical pain/pathology were analyzed separately. We computed: (1) the total number of domains of impact identified; (2) the frequency (%) each domain was listed 1st; (3)the frequency (%) each domain was listed 1st, 2nd, or 3rd

Cervical pathology (n=200 people).

19 domains were identified. Of domains identified as first most important (n=164) 3 domains predominated: work (28%), sleep (24%), walking (24%). Others ranged from 0 – 7.6%. Of all domains identified by all people (n=399), 4 predominated: sleep (62%), work (54%), walking (41%) sitting (36%). Others ranged from 0.6% to 9.8%.

Thoraco-Lumbar pathology (n=537 people).

25 domains were identified. Of domains identified as first most important (n=429) 4 domains predominated: walking (49%), working (18%), sitting (12%) and sleeping (11%). Others ranged from 0 – 7.6%. Of all domains identified by all people (n=1096), 4 predominated: sleep (76%), work (50%), walking (47%) sitting (45%). Others ranged from 0.2% to 11.9%.

Conclusions: People with spinal problems consistently identify 4 main domains of impact: working, walking, sleeping and sitting. This is not reflected by SF-36 and ODI. Further work is required to ensure that scale selection for assessing the impact of spinal pathology and its management is evidence based.

Ethics approval: none

Interest statement: none

Aim: To determine the distribution of pain which can be most reliably attributed to individual lumbo-sacral nerve root compression.

Introduction: Patients are selected for nerve root decompression based on a correlation between symptoms, signs and imaging findings. However, the belief that a given pain may be attributable to a specific nerve root varies widely between surgeons. Some will only consider decompressing a nerve root in the presence of pain radiating in a classical dermatomal distribution whilst others consider nerve root compression to be a cause of back, buttock or thigh pain.

We sought to determine the distribution of pain which significantly improves following decompression of lumbo-sacral nerve roots.

Methods: Data from consecutive patients undergoing lumbo-sacral nerve root decompression between 2002 and 2005 was prospectively analysed. Inclusion criteria were:

uni- or bilateral single level nerve root decompression

For individual nerve roots the distribution of pain described on post-operative pain drawings was sub-tracted from that described on pre-operative pain drawings. This produced a composite pain drawing demonstrating the distribution of pain most reliably improved by decompressing a particular nerve root.

Results: 52 cases fulfilled the inclusion criteria. There were 6 L4, 36 L5 and 17 S1 nerve root decompressions. The distribution of dramatically improved pain following nerve root decompression did not follow the classic dermatomal patterns described in standard text books.

Conclusions:

Pain as a consequence of lumbo-sacral nerve root compression does not appear to be restricted to classical dermatomal distributions.

Aim: To determine any difference which may exist between the interpretation of nerve root compression demonstrated by an MRI scan as assessed by a radiologist compared to a spinal surgeon.

Introduction: There are a few standardized criteria for attempting to quantify the degree of lumbosacral nerve root compression demonstrated by radiological investigations. However, these are not validated and are not commonly employed. It is possible that the interpretation of films by surgeons is different to that by radiologists. If this is the case it could have important consequences, particularly if potential surgical targets are not recognised. We sought to investigate this potential discrepancy.

Method: Data from consecutive patients undergoing lumbosacral nerve root decompression, by a single surgeon, between 2002 and 2005 was prospectively analysed. Inclusion criteria were:

uni- or bilateral single level nerve root decompression

The MRI report of these patients was then scrutinised to see if the decompressed nerve root had been reported as significantly compressed on the pre-operative scan.

Results: Only 75 % of films had a formal radiological report. Of reported films 22% had not reported the surgical target which rose to 33% for L5 nerve root compression.

Conclusion: Consideration needs to be given to the potential placebo effect of surgery, the nature of the compressive pathology, the clinical details supplied to the radiologist and how the surgical decision making was made.

However, in this sample a large minority of MRIs had no formal report. Of those that were reported, there was underreporting of potential surgical targets by radiologists. This implies that there could be a high incidence of false negative MRI reporting with potentially treatable conditions being unrecognised.

Background: Clinical trials of surgery increasingly use disability and quality of life scales as their primary outcome measures. As such, they are the central dependent variables on which treatment decisions are based. It is therefore essential that these scales provide clinically meaningful and scientifically sound (reliable and valid) measurements.

Aim: The aim of this study was to determine if three scales used widely for spinal surgery (the Short form 36 item health survey – SF-36, Oswestry and Neck Disability Indices – ODI, NDI) satisfied basic requirements for reliable and valid measurement, and if they were suitable to detect clinically significant change.

Method: We analysed data from 147 people undergoing cervical (SF-36, NDI), and 233 people undergoing lumbar (SF-36, ODI) spine surgery. We tested the full range of measurement properties of these scales. These included the assumption that adding up items generates meaningful scores and, if that test was passed, scale targeting to study samples, reliability, validity and responsiveness.

Results: In both samples, the SF-36 had problems. Some scales had notable floor and ceiling effects. As a consequence they were unable to detect change. Other scales failed validity tests. Importantly, there was no support for using SF-36 summary scores in either cervical or lumbar surgery. With the ODI and NDI, there were problems with the individual questions. Specifically, the item response options were not working as anticipated. This compromises the reliability and validity of both scales.

Conclusions: This study, whose aim was to assess three scales used to evaluate surgery, not the surgery itself, demonstrates that all three have important limitations and questions their suitability for this crucial role. Essentially, all three scales give inaccurate estimates of treatment effectiveness. The result is that the benefits of spinal surgery are almost certainly being under-evaluated and spinal surgeons are selling themselves short.

Introduction: In people with lumbosacral nerve root compression, the perceived leg pain is expected to be in a dermatomal distribution. In practice, this is not the case, the most common hypothesis being inter-individual variability in the dermatomal supply by nerve roots. Our alternative hypothesis is that pain can be perceived anywhere in the sclerotome innervated by the compressed root. We tested this hypothesis.

Methods: We included patients with MRI-supported single nerve root compression (uni- or bilateral) who underwent decompression by one surgeon (TG) between 2002 and 2005 and who reported improved or resolved pain at follow-up.

Everyone drew the distribution of their pain on a standard template and graded their pain using a visual analogue scale (VAS) before and after surgery (3–6 months). Successive pain drawings for each nerve root were superimposed.

Results: 54 nerve roots were decompressed (S1=17, L5=31, L4=6).

S1 nerve root compression was associated with pain in the lower back, buttock and thigh.

Conclusion: This small preliminary study implies that pain in lumbosacral nerve root compression is more sclerotomal than dermatomal in its distribution.

Study Design: Retrospective outcome measurement study.

Objective: To study the functional outcome of surgery for patients presenting with severe extradural spinal cord compression.

Subjects: All patients who: 1) were surgically treated for spinal cord compression between January 2001 and December 2003, 2) presented with Frankel grade A, B or C, 3) had extradural spinal cord compression secondary to tumour or infection, and 4) were operated on by a single surgeon.

Outcome: Pre- and post-operative functional assessment was made by medical staff, a physiotherapist or both, using the Frankel grading. Frankel grade at 3 months was taken as the end point, unless death had occurred before this time, in which case the best postoperative Frankel’s grade was used.

Results: The records of 41 patients with spinal extradural tumour or infection were reviewed. Fourteen patients had Frankel grade A, B, or C. Four were female and 10 male. The median age of the group was 63.5 (range 36 to 73 years). Two had infection and 12 had tumour. The surgical objective was to decompress the neural elements and to restore and maintain the alignment of the vertebral column. One patient had multiple laminotomies alone. Ten had posterior decompression and fusion. Three had anterior and posterior decompression and fusion. Twelve immobile patients became mobile (Frankel grade D and E) and two remained unchanged. Complications were; two superficial wound infection treated with antibiotics, one deep-seated infection requiring open drainage and one extradural haematoma requiring evacuation.

Conclusions: Appropriate spinal cord decompression and reconstruction of the spinal column has a very good chance of restoring spinal cord function despite the severity of the presenting neurological deficit.