Aim:

Right-Handed Girls With Rt-Ais Measured Using Holtain Equipment Have Upper Arm Length Asymmetry (Right-Minus-Left) Which Is: 1) Relatively Longer On Scoliosis Curve Convexity; 2) Significantly Associated With Scoliosis Curve Severity (Cobb Angle And Apical Vertebral Rotation); And 3) Transient, Decreasing With Age And Years After Menarche [1,2]. The Aim Is To Test Whether The Right Upper Arm Length Relative Overgrowth And Spinal Deformity Severity Were Associated With Right Or Left Upper Arm Length Size-For-Age.

Introduction

In patients with adolescent idiopathic scoliosis (AIS), anomalous extra-spinal left-right skeletal length asymmetries in upper limbs, periapical ribs, and ilia beg the question as to whether these bilateral asymmetries are connected in some way with pathogenesis. The upper arm and iliac length asymmetries correlate significantly with adjacent spinal curve severity respectively in thoracic and lower (thoracolumbar and lumbar) spine. In lower limbs, skeletal length asymmetries and proximo-distal disproportion are unrelated to spinal curve severity. Overall, these observations raise questions about mechanisms that determine skeletal bilateral symmetry of vertebrates in health and disorder, and whether such mechanisms are involved in the cause of this disease. We investigated upper arm length (UAL) asymmetries in two groups of right-handed girls aged 11–18 years, with right thoracic adolescent idiopathic scoliosis (RT-AIS, n=98) from preoperative and screening referrals (mean Cobb angle 45°) and healthy controls (n=240).

Compare the prevalence of psychological distress in claustrophobic patients compared with a non-affected group, together with determination of presenting disability and overall intervention rates.

Retrospective case notes review.

33 patients (13 males) all requiring MRI scan under sedation for claustrophobia (Group 1) were compared with an age and sex matched cohort that had MRI without sedation (Group 2). Both groups were drawn from the same chronic back clinic. Average age in both groups was 54 years (range 27-79 years). Both groups had standard conservative therapy, together with psychometric evaluation.

Primary: Zung Depression Index (ZDI), Modified Somatic Perception Questionnaire (MSPQ). Secondary: Oswestry Disability Index (ODI), intervention rates (surgery, injections and physiotherapy sessions)

Comparison of means -

22 patients (66.7%) in Group 1 were discharged after their MRI with no intervention compared to 7 patients (21.2%) in Group 2.

Claustrophobic patients with back pain showed higher levels of depression than non-claustrophobic patients, with a greater prevalence of psychological distress. Disability however was the same. The majority of claustrophobic patients had no intervention, with a lower rate than their non-claustrophobic peers. Claustrophobia is a proxy for psychological distress and should be considered in the overall evaluation of chronic back patients.

To determine the cost-effectiveness of Lumbar Total Disc Replacement (LTDR) with circumferential spinal fusion surgery.

Cost utility analysis.

We prospectively reviewed a cohort of 32 consecutive patients who underwent LTDR between 2004 and 2008 with a mean follow-up for 3.75 years. Identical data was compared to a similar group of patients (n=37) who underwent fusion in our institution.

Oswestry Disability Index, visual analogue scale, quality of life (SF-36) and NHS resource use. Cost-effectiveness was measured by the incremental cost per quality-adjusted life year (QALY) gained. QALY gains were estimated from SF-36 data using standard algorithms.

There was no significant intergroup difference in the ODI, VAS and SF-36 pre and post-op. Both treatments produced statistically significant and equivalent improvements in mean health state utility at the 24-month follow-up (0.078 for LTDR, 0.087 for fusion). Costs were significantly lower with LTDR than with fusion due to a shorter mean procedure time (193.6 vs 377.4 minutes) and shorter length of stay (5.8 vs 7 days). The mean cost difference was £2,878 per patient. At 2 years, the cost per QALY gain of the lower-cost option (LTDR) was £48,892 although the cost effectiveness ratio would fall to below £30,000 if it is assumed that the patient benefits of LTDR last for at least 4 years.

Both treatments led to significant improvements in patient outcomes which were sustained for at least 24 months. Costs were lower with LTDR which is effective and a more cost-effective alternative.

To evaluate the cost-effectiveness IDET relative to circumferential lumbar fusion with femoral ring allograft (FRA).

Cost-effectiveness analysis

Patient-level data were available for patients with discogenic low back pain treated with FRA (n=37) in a randomized trial of FRA vs. titanium cage, and for patients recruited to a separate study evaluating the use of IDET (n=85). Patients were followed-up for 24 months.

Oswestry Disability Index, visual analogue scale, quality of life (SF-36), radiographic evaluations, and NHS resource use. Cost-effectiveness was measured by the incremental cost per quality-adjusted life year (QALY) gained.

Both treatments produced statistically significant improvements in pain, disability and quality of life at the 24-month follow-up. Costs were significantly lower with IDET due to a shorter mean procedure time (377.4 minutes vs. 49.9 minutes) and length of stay (7 days vs. 1.2 days). The mean incremental cost of IDET was -£3,713 per patient; the mean incremental QALY gain was 0.03. At a threshold of £20,000 per QALY the probability that IDET is cost-effective is 1, and the net health benefit is 0.21 QALY per patient treated.

Both treatments led to significant improvements in patient outcomes which were sustained for at least 24 months. Costs were lower with IDET, and for appropriate patients IDET is an effective and cost-effective treatment alternative.

Ethics approval: Ethics committee COREC

This cost-effectiveness analysis was carried out by the York Health Economics Consortium at the University of York, and was funded by Smith & Nephew. Smith & Nephew had no financial or other involvement in the collection or analysis of the data on which the CEA is based.

Determine the detection rate of modern spinal implants using the current technology.

There is a paucity of data regarding detection rates of modern spinal implants using modern walk-through pulsed archway metal detectors (AMDs). No published reports compare detection capability with hand-held metal detectors (HHMDs).

ex-vivo & in-vivo comparison of detection rates using AMD & HHMD (set to maximum DoT sensitivities), in patients of varying Body Mass Index (BMI), implants, implant mass/density and alloys.

40 patients with: lumbar disc replacement (CoCr) (n=8), cervical disc replacement (CoCr) (1), posterior deformity instrumentation (17), anterior deformity instrumentation (2), anterior reconstruction (2), PLIF (6), interspinous distraction device (1), anterior cervical plate (2) ALIF (1), All implants were titanium unless indicated. Mean metal mass was 98g (range 6g-222g).

The AMD did not detect any instrumentation individually or in combination up to a titanium mass totalling 215g. The HHMD detected all instrumentation at a distance of 5cm; with the minimum mass being 2g

No implants were detected in patients by the AMD. The HHMD did not detect any anterior lumbar or thoracic surgical implants. It detected anterior cervical implants. The HHMD detected all posterior surgical implants. There was no significant relationship between detection, BMI, total metal mass, and metal density/segment.

AMD detectors do not detect modern spinal implants. HHMD detect all modern posterior spinal implants; this has implications for patient documentation.

Comparison of efficacy of multi-modality spinal cord monitoring [SCM] (SSEP & MEP) in surgery of paediatric deformity using two classification systems I (traditional) vs. II (modified).

SSEP SCM has low sensitivity in a normal spinal cord; this is only marginally improved with additional MEP monitoring. Traditional definitions of a ‘false’ positive' test ignores anaesthetic & surgical interventions following notification of altered SCM signals.

Retrospective, paediatric cohort.

232 patients; mean age 14 years (26% males). 68% idiopathic scoliosis; 62% posterior surgery.

Primary: Post-operative neurologic deficit. Secondary: significant (>50%↓ amplitude) SSEP or any MEP loss.

PPV- Positive predictive value, NPV- Negative predictive value; LR+ve- Positive likelihood ratio, LR-ve Negative likelihood ratio; N/C – Not calculable

Efficacy of SCM is determined by definitions of ‘false positive’. System II classification was more efficacious and reflects current surgical practice.

Comparison of clinical, radiological & functional outcomes of corrective surgery for right thoracic AIS curves.

There is a paucity of data relating functional outcomes to the radiological and surface measurement results of either posterior or anterior surgery for right thoracic AIS.

Prospective, cohort study, mean follow up 35 months (range 9-115)

38 patients (6 males); 22 Lenke 2 posterior, 16 Lenke 1 anterior.

Primary= rib hump, radiological (frontal Cobb correction, apical vertebral translation AVT, sagittal profile), Modified SRS Outcomes Instrument (MSRSI). Secondary= estimated blood loss (EBL), operative time, complications

No significant difference at P<0.005 with student t-test unless indicated

Rib Hump: 16° posterior 17 ° anterior, corrected to 8 ° (50%) and 6 ° (60%) respectively.

Thoracic Cobb: 70° posterior 61 ° anterior, corrected to 27° (61%) and 22° (64%) respectively. No difference in preoperative curve flexibility or fulcrum bending correction index. Thoracic AVT 55% correction posterior, 70% anterior, Lumbar Cobb 59% correction posterior, 52% anterior. Thoracic kyphosis significantly reduced in posterior surgery (35 ° to 20 °) and significantly increased with anterior surgery (21° to 30°). Lumbar lordosis significantly reduced with posterior surgery (88° to 47°), no significant change with anterior surgery (60° to 53°).

MSRSI; Domain scores similar preoperatively between groups. Difference scores (postop-preop), higher scores=better. Pain: +1.21 posterior +0.73 anterior. Self image: +1.02 posterior +0.71 anterior. Function/activity: +0.28 posterior +0.21 anterior. Mental health: +0.66 posterior +0.45 anterior.

No significant difference in complication rate, operative time or estimated blood loss

Similar cohorts of AIS patients treated by either anterior or posterior surgery have no significant differences in radiological or functional outcomes. The different final sagittal profile in both groups did not affect the MSRSI outcomes. Both procedures deliver significant health gains as measured by the MSRSI.

To determine the factors that influences the clinical outcomes in surgical correction of thoracic AIS.

There are conflicting data regarding the effects of back shape and radiologic parameters on the self-reported outcomes of surgery in AIS.

Prospective, cohort study; mean follow-up 29 months (range 9-88)

30 patients (5 males);

Rib hump 17 ° corrected to 7 °.

Thoracic Cobb 66 ° corrected to 25 ° (63%). Lumbar Cobb 42 ° corrected to 17°. Thoracic apical vertebral translation (AVT) 48mm corrected to 18mm. Lumbar AVT 34mm corrected to 19mm. Thoracic kyphosis 29° preoperatively 23° postoperatively. Lumbo-sacral lordosis 57° preoperatively 49° postoperatively

Modified SRS Outcomes Instrument (MSRSI) filled out pre-operatively and at final follow up.

Primary= rib hump, radiological (frontal Cobb correction, lumbar & thoracic AVT, sagittal profile), Modified SRS Outcomes Instrument (MSRSI) domain scores.

The magnitude of the rib hump had a significant association with pain:

Rib hump vs. MSRSI pain r= -0.55 p<0.000

Similar correlations existed between rib hump and self-image (r=-0.64, p<0.0000), thoracic Cobb angle with pain (r=-0.48 p<0.0001) and self-image (r= -0.57, P<0.0000). The postoperative thoracic Cobb angle, and percentage thoracic Cobb correction had significant correlations with self-image (r=-0.55 p=0.003 & r=0.54 p0.004 respectively).

The size of the rib hump has a significant impact on pain & self-image. These domains are also significantly influenced by the residual thoracic Cobb angle and overall scoliosis correction.

Aim

To evaluate morbidity and outcome associated with lumbar spine decompression for central spinal stenosis in the elderly compared with younger age groups.

We aimed (1) to determine the factors which influence outcome after surgery for CES and (2) to study CES MRI measurements. 56 patients with evidence of a sphincteric disturbance who underwent urgent surgery (1994-2002) were identified and invited to clinic. 31 MRIs were available for analysis and randomised with 19 MRIs of patients undergoing discectomy for persistent radiculopathy. Observers estimated the percentage of spinal canal compromise and indicated whether they thought the scan findings could produce CES and whether the discs looked degenerate. Measurements were repeated after two weeks.

(1) 42 patients attended (mean follow up 60 months; range 25–114). Mean age at onset was 41 years (range 24–67). 26 patients were operated on within 48 hours of onset. Acute onset of sphincteric symptoms and the time to operation did not influence the outcomes. Leg weakness at onset persisted in a significant number at follow-up (p<0.005). Bowel disturbance at presentation was associated with sexual problems (<0.005) at follow-up. Urinary disturbance at presentation did not affect the outcomes. The 13 patients who failed their post-operative trial without catheter had worse outcomes. The SF36 scores at follow-up were reduced compared to age-matched norms in the population. The mean ODI was 29, LBOS 42 and VAS 4.5.

(2) No significant correlations were found between MRI canal compromise and clinical outcome. There was moderate to substantial agreement for intra- and inter-observer reproducibility.

We report a prospective case-series study to evaluate the results of non-operative and operative treatment of symptomatic unilateral lumbar spondylolysis. Non-operative treatment results in healing in most patients with symptomatic unilateral spondylolysis. Surgery however is indicated when symptoms persist beyond a reasonable time affecting the quality of life in young patients particularly the athletic population.

We treated 41 patients [31 male, 10 female] with suspected unilateral lumbar spondylolysis. Thirty-one patients were actively involved in sports at various levels. Patients with a positive stress reaction on SPECT imaging underwent a strict protocol of activity restriction, bracing and physical therapy for 6 months. At the end of six months, patients who remained symptomatic underwent a Computed Tomography [CT] scan to confirm the persistence of a spondylolysis. Seven patients subsequently underwent a direct repair of the defect using the modified Buck's Technique. Baseline Oswestry disability index [ODI] and Short-Form-36 [SF-36] scores were compared to two year ODI and SF-36 scores for all patients.

In the non-operated group, the mean pre-treatment ODI was 36 [SD=10.5], improving to 6.2 [SD=8.2] at two years. In SF-36 scores, the physical component of health [PCS] improved from 30.7 [SD=3.2] to 53.5 [SD =6.5] [p<0.001], and the mean score for the mental component of health [MCS] improved from 39 [SD=4.1] to56.5 [SD=3.9] [p<0.001] at two years. 20/31 patients resumed their sporting career within 6 months of onset of treatment, a further 4/31 patients returned to sports within one year.

The seven patients who remained symptomatic at six months underwent a unilateral modified Buck's Repair. The most common level of repair was L5 (n=4). The mean pre-operative ODI was 39.4 (SD=3.6) improving to 4.4 (SD=4) at the latest follow-up. The mean score of PCS [SF-36] improved from 29.6 [SD=4.4] to 51.2 [SD=5.2] (SD=5.2) (p<0.001) and the mean score of MCS (SF-36) improved from 38.7 (SD=1.9) to 55.5 (SD=5.4) (p<0.001).

A specific protocol of conservative treatment for patients with a unilateral lumbar spondylolysis resulted in a high rate of success with 83% of patients avoiding surgery. If symptoms persist beyond a reasonable period (i.e. 6 months) and reverse gantry CT scan confirms a non-healing defect of the pars interarticularis one may consider a unilateral direct repair of the defect with good outcome ultimately.

The NDI is a simple 10-item questionnaire used to assess patients with neck pain. The original validation was performed on 52 patients with neck pain and the test-retest on 17 whiplash patients with a 2-day interval. The SF36 measures functional ability, wellbeing and the overall health of patients. It is used in health economics to assess the health utility, gain and economic impact of medical interventions.

Objectives were to independently validate the NDI in patients with neck pain and to draw comparison between the NDI and SF36. 160 patients with neck pain attending the spinal clinic completed self-assessment questionnaires. A second questionnaire was completed in 34 patients after a period of 1-2 weeks.

The internal consistency of the NDI and SF36 was calculated using Cronbach alpha. The test-retest reliability was assessed using the Bland and Altman method and the concurrent validity between the two questionnaires was assessed using Pearson correlation.

Both questionnaires showed robust internal consistency: SF36 alpha = 0.878 (se=0.014, 95%CI=0.843 to 0.906) and NDI = 0.864 (se=0.017, 95%CI=0.825 to 0.894). The NDI had significant correlation to all eight domains of the SF36 (p<0.001). The individual scores for each of the ten items had significant correlation with the total disability score (p<0.001). The test-retest reliability of the NDI was acceptable.

We have shown irrefutably that the NDI has good reliability and validity and that it stands up well to the SF36.

Background: Treatment of high-grade spondylolisthesis remains controversial. In-situ fusion does not address the sagital balance, reduction and fusion on the other hand is associated with unacceptably high rate of neurological complications.

Aim: To describe the results of a novel technique using Magerl External Fixateur for gradual reduction followed by circumferential fusion.

Methods: From 1988 to 2006, thirteen patients were treated with this technique at our institution. They all had high grade spondylolisthesis. Retrospective case note review and radiographic analysis were carried out. 10 point Visual Analogue Sore (VAS) for pain, Oswestry Disability Index (ODI), Low Back Outcome Score (LBOS), SF-36 Health Survey, and Patient Satisfaction Questionnaire were collected. Complete set of data was available for 9 patients, 7 Female and 2 Male. Mean age at operation was 16 years (range 12–22), and average length of follow-up was 11 years (range 5–19)

Results: Post operatively, Percentage of Slip was improved by an average of 70%(range 32–96%)(p=0.001), Slip Angle by 72%(p=0.0001) and sacral Inclination by 59%(p=0.0016). Radiological fusion was achieved in all but one. VAS for leg and back pain improved from 8.4 (range 8–9) and 8.2 (range 6–10) to 0.8(range 0–2) and 1.2 (range 0–2) respectively. These improvements were statistically significant (p< 0.001). ODI at the latest follow-up averaged 8% (range 0–16%) and LBOS 56.6 (range 44–70). The mean SF-36 for physical domains was 87.5 (range 80–93) and that for the psychological domains was 91.25 (range 81–100). All patients were fully satisfied. 3 cases had culture negative excessive discharge from one pin site. 2 patients developed transient parasthesia and one patient developed asymptomatic pseudoarthrosis.

Conclusion: Our technique albeit in a small cohort of patients, achieved significant correction of the commonly used and widely accepted radiological measurements without any neurological complications. The radiological improvement was also reflected in statistically significant improvement in validated outcome measures.

Introduction: Accurate and ethical coding is challenging and directly impacts on Payment by Results (PbR). The aims & objectives of this study were to review the existing pattern of coding for spinal surgery and ascertain its appropriateness & accuracy for surgical procedures, medical co-morbidities and post-op complications.

Methods: A retrospective review of 70 consecutive cervical and 100 consecutive lumbar spine patients who were operated from April 2006 onwards was conducted. The excel sheet provided by coding department, hospital notes – clinic letters, physicians’ entries, theatre notes and laboratory reports (biochemistry/microbiology/histology) – were reviewed. Of the 170 cases, 165 were available for analysis.

Results: Coding data of 5 patients who underwent cervical spine surgeries were not available. Of the 165 cases, the accuracy of primary procedural codes was 93.9% (90.8% cervical & 96% lumbar). However this reduced to 77.6% (75.4% cervical & 79% lumbar) when the accuracy for entire description of performed surgery was considered. The procedural codes did not specifically reflect the surgery performed and lacked reproducibility. Surgical levels were coded incorrectly in 9% of the cases. Cervical surgeries were coded as lumbar in 4 and posterior surgery as anterior in 3 cases respectively. Harvest of iliac crest bone graft was not coded in 5 cases. Medical comorbidities were coded appropriately in 64.2% of the patients (55% cervical & 70% lumbar). The commonly missed comorbidities were drug allergies, hypercholesterolemia, smoking and alcoholism. Post-op adverse events were coded in 75% of the cases (16/20 cervical & 5/8 lumbar). The accuracy was better for lumbar as compared to cervical spinal surgeries.

Conclusion: Coding is a universal language of communication amongst healthcare professionals. Its accuracy is important not just for PbR, but for data quality, audit and research purposes too. The financial implications regarding PbR governed by HRG codes (dictated by OPCS 4.4 & ICD–10 codes) are discussed. The awareness of clinical coding is low amongst junior doctors. Following this study, a clinical coding facilitation form has been introduced to improve data quality. Our plan is to close the audit loop and re-evaluate. Literature emphasises qualification of coders, legible documentation by physicians and interaction between coders and clinicians.

Introduction: The literature regarding the functional outcome following C1–C2 surgeries for non-rheumatoid C1–C2 pathologies following selective arthrodesis is sparse.

Aim: To determine the long term correlation between functional outcome and radiological determinants following C1–C2 fusion for conditions other than RA.

Methods: All C1–C2 surgeris performed between 1988–2002 for non-RA etiologies were reviewed retrospectively. Selective C1–C2 fusion performed in 32 pts with a min f/u of 5 yrs formed the study group. The mean age at surgery was 57.2 yrs (r 22–84yrs). The etiologies were trauma (15), non-union (6), congenital AAD (2), C1–C2 deg. arthropathy (2), os odontoideum (2), tumours (4) and instability due to TB (1). Neurodeficit were present in 7 pts. Transarticular (TA) screws supplemented with posterior wiring was performed in 27 & posterior wiring alone in 5 pts respectively. A monocortical H-shaped autograft from iliac crest was used in all cases. There were two deaths & two pts were lost for F/U. The mean F/U was 7.8 yrs (r 5–13 yrs). Disability & pain using NDI & VAS and subjective satisfaction were recorded in all pts. We measured 1) C1/2 fixation angle, 2) Inclination of C1, 3) Anterior shift of C2 and 4) C2–7 lordosis on pre and final F/U lateral x-rays.

Results: Optimal TA screw placement was seen in 78.5% of pts. The mean improvement in NDI & VAS were from 55.4% to 19.6% and 8.4 to 1.6 respectively and was better in younger pts. Fusion was seen radiologically in 82.1% of pts at 12 mo post surgery. Segmental stability and resolution of symptoms was seen in all patients despite implant failure in 4 and incomplete fusion 5 cases respectively. Two wound dehiscences needed debridement of which one elderly pt died of MRSA sepsis 2 mo post-op. The C1–C2 segmental lordosis was significantly increased by surgery (−4.2 0 vs. −11.80; P=0.016). The subaxial cervical spine became less lordotic in initial few months post-op but eventually regained more lordosis as time progressed. The C1 inclination came into more extended position w.r.t horizontal line post-op with minimal loss of inclination subsequently. C1–C2 fixation angle and anterior shift of C2 did not have significant correlation with long term functional outcome i.e. NDI and VAS (r=0.35, p=0.17).

Conclusion: The functional outcome following C1–C2 arthrodesis is usually good despite metalwork issues and incomplete fusion in these selective group of non-rheumatoid arthritis pathologies.

Study Design: Long-term retrospective case review of function in children with early onset scoliosis managed by selective anterior epiphysiodesis and posterior ‘Luque trolley’ growing instrumentation

Method: spinal and clinical function was assessed utilising SRS-22 and SF-36 outcome measures. The rates of secondary surgical procedures and further definitive fusion were recorded. Pulmonary function was assessed by standardised and averaged spirometric data at follow up.

Results: 25 patients have been clinically reviewed and functionally assessed (age range 6–35 years) mean age 17.7 years at follow up. 16 patients have reached skeletal maturity (8males, 8females) with mean follow up 11.8 years, to a mean age of 22.4 years. clinically 80% of cases were well balanced. At maturity the average loss of axial spinal growth measured 10.25cm (arm span- standing height) (range +4 cm to −21cm). In the immature cohort still growing, median shortening was 0.75%, with average height loss 1.63% of predicted. SRS- 22 and SF-36 questionnaires indicated moderate – good functional outcomes in 80% of patients. Spirometric data, with one case incapable of test compliance, demonstrates 24 % of patients had normal spirometric functional parameters, 32% had mild restrictive deficits, 12% had moderate and 28% had severe restrictive deficits. Poor spirometric function did not correlate with poor outcome measures. Over 50% had required further surgery.

Conclusions: Poor functional outcomes occurred in patients requiring early and multiple surgical revision procedures associated with loss of control or fixation of primary and secondary spinal deformities.

Study design: A retrospective review of patient records with recent clinical and radiographic assessment.

Objective: Long-term evaluation of the Luque trolley for posterior instrumentation in congenital scoliosis.

Summary of background data: From a group of 51 cases treated with the Luque trolley, we review 10 patients with progressive congenital scoliosis (5male, 5female) for a mean follow-up period of 14.8 years, to mean age of 19 years. The mean Cobb angle of the primary curve before surgery was 69.5 degrees. The mean Cobb angle of the secondary cervico-thoracic curve before surgery was 37.1 degrees and of the caudal secondary curve was 26.4 degrees. The mean age at surgery was 5.0 years. 8 patients had a selective epiphysiodesis procedure, 2 with hemi-vertebrectomy, and all underwent single- stage (7 patients) or dual-staged (3 patients) posterior instrumentation with a Luque trolley growing construct.

Method: Clinical evaluation and sequential measurements of Cobb angle were done, with recording of further surgical procedures, associated complications, and final coronal balance. The thoracolumbar longitudinal spinal growth (T1-S1) and growth in the instrumented segmented were also calculated.

Results: The mean preoperative primary curve Cobb angle of 69.5degrees, corrected to a mean postoperative angle of 30.6 degrees, with progression from here to curve magnitude of 38.8 degrees on latest follow up (approximate rate of progression of 0.55 degrees per year).

The mean pre-operative cephalic (cervico-thoracic) Cobb angle of 37.1degrees, corrected to 22 degrees, with progression to 26.6 degrees.

The mean pre-operative caudal (lumbar) Cobb angle of 26.4degrees, corrected to16.2 degrees, this later progressed to 20.6 degrees.

Coronal plane translation measured 1.68 cm at latest follow up [range 0.5–5.1cm].

The thoracolumbar longitudinal growth measured a mean of 8.81cm (approx0.8 cm/year) with a recorded lengthening of 2.54 cm (approx 0.23cm/year) in the instrumented segmented. Half the patients did not require further surgery.

Conclusion: Selective fusion does not always prevent further deformity in congenital scoliosis. The addition of posterior growing construct instrumentation did demonstrate capacity for good correction of primary and secondary curvatures and a limited capacity for further longitudinal growth.

Type of study: Case-series comparison.

Patients: 20 patients (2 males); average age 15.5 years; mean follow-up 22 months. 10 patients (Lenke type 1) had anterior correction and instrumentation; 10 patients (Lenke type 2) had posterior operations. All patients had a selective thoracic fusion (with the type 2 curves having instrumentation incorporating the proximal thoracic curve).

Outcome measures: Complications, radiological parameters (Cobb correction of major & compensatory curves); trunk shape (rib hump / scoliometer), and SRS-22 questionnaires.

SRS-22 outcomes: There was no significant difference in the pre-operative individual domain scores (pain, self-image, function, mental health, satisfaction) between the two groups. There were no differences in the postoperative results (including self-image) apart from pain. The anterior surgery group had more persistent pain, but at a similar level than preoperatively (3.2 [0.8] vs 4.6 [0.3], p~0.03).

Conclusion: For right thoracic (Lenke curve types 1& 2) late-onset idiopathic scoliosis both types of surgery deliver similar radiological and trunk-shape results. SRS-22 self-image and function post-operative results are also similar. The anterior procedure did not however improve the pre-operative pain score.

Background: It is often useful to gauge the flexibility of curves while assessing patients with scoliosis. Our aim was to discover if there were any reliable x-ray predictors of stiffness.

Methods: Previously the flexibility index has been shown to be an accurate measure of curve stiffness. A random selection of fifty x-ray sets was analyzed for parameters that might predict flexibility. These were then compared to the flexibility index generated from bending films. We recorded age; Cobb angle; bending film Cobb angle; Perdriolle rotation assessment; percentage wedging of the apical vertebrae and translation of the apex of the curve from a central sacral/cervical line. We then calculated the flexibility index. All measurements were taken from immediately pre operative standing AP x-rays and fulcrum bending films (1). The group was then assessed as a whole and subgroups were analyzed. Large curves (> 50 degrees) were compared to small (< 50 degrees) curves and thoracic curves were compared with thoracolumbar curves. Correlation between the flexibility index and the other parameters was then studied. We used Pearson correlation coefficient for parametric data and the Spearman rank correlation coefficient to study the non parametric data. P values were then assigned using a statistics software package.

Results: Age and apical translation were not related to curve stiffness. The Cobb angle was the only strong predictor of flexibility (p-0.002) looking at all curve types together. The Cobb angle was, however, more useful in larger curves and did not reach statistical significance in the small curve subgroup. In small curves Perdriolle rotational assessment was a more useful measurement (p-0.02). In the thoracic curve subgroup the percentage wedge of the apical vertebrae was a strong predictor (p-0.007).

Conclusion: Our sample had a strong bias toward an adolescent age group (5–61) mean age 17 and probably did not have enough of a spread to demonstrate the previous relationship between age and stiffness (2). The study re enforces the value of the Cobb angle in predicting curve stiffness but suggests caution using it in smaller curves. It also suggests a role for Perdriolle measurement in small curves and percentage apical wedge in thoracic curves.