Purpose

A Virtual Spinal Clinic (VSC) was set-up at a regional spinal referral centre to see if patient care could be improved through early advice to provide timely management, early onward referral, improve patient satisfaction and minimise chronicity. The clinic was based on the successful virtual model used throughout the country within orthopaedic fracture clinics. VSC is a Consultant led multi-disciplinary (MDT) clinic run by Advanced Practitioners (AP).

Introduction

Many journals require outcome data at 2 years post-operative for the assessment of operative procedures in spinal surgery. This study seeks to clarify the timescale of improvement after surgery to see if a shorter period of assessment will indicate the final outcome.

Purpose of the study

In a recent study, O'Leary et al. [2005] reported their observations on the patterns of Charité disc prosthesis motion under physiologic loads. The purpose of this study was to investigate whether the motion patterns observed in the in vitro model are replicated in clinical practice.

Aim: This study presents analysis of the largest case series to date in the published literature of patients with Hurler Syndrome, to identify the severity of thoraco-lumbar kyphosis, risk factors for progression and results of intervention.

Methods and Results: Forty two patients with MPS-I had treatment with Bone-marrow transplantation and/ or enzyme replacement therapy between June 1995 and October 2007. These patients had regular systematic clinical review and were seen at least annually. Standing lateral radiographs of the thoracolumbar spine were retrieved and analysed.

At initial examination (average age 1y 1m) the thoracolumbar kyphosis measured a mean of 39.6 degrees (SD 12 degrees). Analysis of non-operatively treated patients revealed that patients with an initial kyphosis angle (average age 1y 2m) of less than 40 degrees were significantly less likely to develop progressive kyphosis over the average follow-up period of 3.5 years (mean initial angle 30 degrees and at final follow-up 34 degrees) than those with an angle greater than 40 degrees (mean angle initially 46 degrees and at final follow-up 61 degrees), p=0.005 (repeated measures ANOVA). Seven patients underwent surgical intervention at mean age of 3 years for progressive deformity with favourable results.

Conclusion: Thoracolumbar kyphosis is of variable severity in Hurler’s syndrome and patient’s who present with a kyphosis angle of greater than forty degrees on initial radiographic examination are significantly more likely to develop progressive kyphosis.

Ethics approval: None

Interest Statement: None

Background: Prader-Willi syndrome is associated with multiple musculoskeletal manifestations including scoliosis, joint laxity, hip dyplasia and lower limb deformity. Scoliosis is reported in almost half of patients with Prader-Willi; however, only a small proportion ever have surgery. The literature suggests that surgery in this group of patients is often difficult. Obesity and apnea cause anaesthetic concern. The surgical procedure is reported as being complicated by excessive intra-operative blood loss, and difficulty with instrumentation; possibly as a result of osteopenia, is described.

Purpose: To compare the experience of scoliosis surgery in Prader-Willi patients in our institution with that previously reported in the literature.

Methods: The notes and x-rays of 6 patients with Prader-Willi syndrome who had corrective scoliosis were reviewed.

Results: Six patients (4 female and 2male) underwent corrective scoliosis surgery. The mean age at which scoliosis was detected in the patients was 5 years (range 2–7years). The mean Cobb angle at time of initial referral was 30° (range 8°–86°). Indication for surgery in all cases was curve progression. The mean age at time of surgery was 11.8 years (range 10–13years). The mean pre-operative Cobb angle was 70° (range 40°–90°) and mean post-operative Cobb angle was 23° (range 10°–40°). Three patients had posterior surgery with instrumentation, one had anterior instrumentation only and two patients had combined anterior release with posterior instrumentation. The most proximal instrumentation levels ranged from T2–T6 and the most distal instrumentation levels ranged from T11-L5. Three patients had all pedicle screw fixation, 2 had hybrid fixation (with screws at curve apex) and one had anterior all screw fixation. The mean operative time was 335 mins (range 190–540 mins) and the mean blood loss was 29% of total blood volume (range 14–55%). Standard anaesthetic technique was used in each case and all patients were extubated immediately after surgery. Patients were discharged on average 8 days post surgery (range 6–14 days). One patient had a wound infection and a stitch granuloma requiring surgical debridement and one patient required trimming of proximal end of rod because it was prominent.

Conclusion: Scoliosis surgery in patients with Prader-Willi offers adequate deformity correction and in our experience is not associated with operative technical difficulty, major complications or a prolonged hospital stay.

Aim: To measure the quality of five major scientific meetings by assessing the publication rate of papers presented and recording their citation index.

Material and Methods: Abstracts of podium presentations at the meetings of the Scoliosis Research Society, International Society for the Study of the Lumbar Spine, British Scoliosis Society, BritSpine and Eurospine were included. We performed a Medline search to identify publications from the abstract. We calculated the time from meeting to publication and recorded the citation rate of the articles.

Results: Of 396 abstracts, 182 were published in peer-review journals – a publication rate of 46%. The publication rates of the five meetings (SRS, BSS, ISSLS, Eurospine, Britspine) were 69%, 53%, 51%, 38%, 24% respectively. Most publications were in “Spine” (55%), then European Spine Journal (11%). The median citation rate of the papers from the SRS, ISSLS, BSS, Eurospine, Britspine meetings was 3, 3, 3, 2, and 1 respectively. The average time to publication was 16 months.

Discussion & Conclusions: Podium presentation is a valuable means for the dissemination of research findings. However, a paper in a peer-reviewed journal is subjected to greater scrutiny, and is perhaps a better indicator of the work’s merit. The average rate of publication in medicine following presentation is 45%1. Spinal meetings are within this range. Although the quality of the scientific work is not the only factor to determine publication, and nor is the quality of the presentations the only factor to assess in evaluating a meeting, the rate of publication and citation rate provide an indicator of the quality and scientific level of meetings.

Aim: To measure the quality of five major scientific meetings by assessing the publication rate of papers presented and recording their citation index.

Material and Methods: Abstracts of podium presentations at the meetings of the Scoliosis Research Society, International Society for the Study of the Lumbar Spine, British Scoliosis Society, BritSpine and Eurospine were included. We performed a Medline search to identify publications from the abstract. We calculated the time from meeting to publication and recorded the citation rate of the articles.

Results: Of 396 abstracts, 182 were published in peer-review journals – a publication rate of 46%. The publication rates of the five meetings (SRS, BSS, ISSLS, Eurospine, Britspine) were 69%, 53%, 51%, 38%, 24% respectively. Most publications were in “Spine” (55%), then European Spine Journal (11%). The median citation rate of the papers from the SRS, ISSLS, BSS, Eurospine, Britspine meetings was 3, 3, 3, 2, and 1 respectively. The average time to publication was 16 months.

Discussion & Conclusions: Podium presentation is a valuable means for the dissemination of research findings. However, a paper in a peer-reviewed journal is subjected to greater scrutiny, and is perhaps a better indicator of the work’s merit.

The average rate of publication in medicine following presentation is 45%¹. Spinal meetings are within this range.

Although the quality of the scientific work is not the only factor to determine publication, and nor is the quality of the presentations the only factor to assess in evaluating a meeting, the rate of publication and citation rate provide an indicator of the quality and scientific level of meetings.

There is an increasing awareness of the need to avoid of homologous blood transfusion in elective surgical practice. This stems from a better appreciation of the adverse effects of homologous blood transfusion and increasing pressure on blood stocks because of increasing restrictions on potential donors.

This study examines the effect of using modern blood conservation methods on the subgroup of our patients having surgery for adolescent idiopathic scoliosis. We chose this group because it is a homogenous group of patients of similar age, all of whom had major surgery of a similar severity, and in whom there were few contraindications to our blood conserving strategies.

We studied 78 consecutive patients with adolescent idiopathic scoliosis who underwent surgery. They were divided into two groups. Patients in the study group had one or more modern blood conservation measures used perioperatively. The patients in the comparison group did not have these measures.

There were 46 patients in the study group and 32 in the comparison group. Eight patients who had anterior only surgery, were excluded. The two groups did not differ in age, body weight, and number of levels fused or the type of surgery.

Only 2 patients in the study group were transfused with homologous blood and even these transfusions were off protocol. Wastage of the autologous predonated units was minimal (6/83 units predonated). In contrast all patients in the comparison group were transfused homologous blood. There was significant decrease (p = 0.005) in the estimated blood loss when all the blood conservation methods were employed in the study group.

Using blood conservation measures, lowering the hemoglobin trigger for transfusion and education of the entire team involved in the care of the patient can prevent the need for homologous blood transfusion in patients undergoing surgery for adolescent idiopathic scoliosis.

Audit is an important part of surgical practice. Commissioners may use it as evidence of quality assurance. No comprehensive audit exists in spinal surgery. Usage of existing databases is disappointing. We developed an audit database which was comprehensive and gathered patient outcomes. The underlying principles were:

All patients having surgery should enter,

Demographic data, OPCS codes, length of stay and other data were downloaded directly from the hospital information systems. A monthly printout of patients enrolled was provided to the audit coordinator. She was responsible for the collection of clinical outcomes at 6 months, 12 months, and 2 years after surgery. The initial audit involved the Northwest and Mersey Regions. Data from the hospital information systems (HIS) for two years were available for comparison. Unfortunately only two centres gathered clinical outcomes. We have continued to gather data. 380 patients have been enrolled. HIS data are available for all. With varying lengths of follow up, there are 1045 potential clinical outcomes available. Only 8 patients (2%; 8 outcomes, 0.76%) have been lost to follow up. Using this data we are able to compare outcomes between surgeons, between surgical procedures, and see changes over time. As far as we know we are the only centre in the UK able to do this. It is a valuable Clinical Governance tool. We believe that the principles underlying this audit are the only means to obtain comprehensive outcome audit in surgery.

We investigate the hypothesis that normal spinal shape is genetically determined raising the possibility that individuals with scoliosis may inherit an ‘at risk’ spinal shape leading to the clustering of scoliosis within families.

A large scale study of spinal topography (Quantec system) in straight-backed sibling pairs of schoolchildren was undertaken. All children had no family or past history of spinal pathology and passed a modified Adams forward bend test. 223 sibling pairs were scanned including 28 heterozygote and 11 homozygote pairs. Control groups were constructed by breaking the sibling pair and replacing the removed sibling with an age, sex matched, unrelated counterpart. A sagittal spine line was extracted and analysed using principal component analysis to produce four scores accounting for 97.5% of the cumulative variation in shape. The scores were analysed by intraclass correlation coefficients (ICC).

The results for the second score were:-

All sibling groups showed greater correlation of sagittal profile for the second principal component than unrelated controls. Significant correlations in shape were seen for both twin groups where no correlation was seen with controls. A significant correlation was observed in same sex pairings. This work suggests that some elements of spinal profile may be familial but also shows correlation with sex. Both of these observations may be important in the aetiology of idiopathic scoliosis.

The aim of the study was to compared the various treatments of femoral diaphyseal fractures in children. The endpoints being length of hospital stay, clinical and functional outcome. The prospective part of the study started with the appointment of a dedicated children’s orthopaedic surgeon in 1999. Prior to this in patient traction was the main treatment. Now early hip spicas for the under 5 year old, Nancy nails for the over fives and external fixation for polytrauma are the treatments of choice.

Anyone under the age of fifteen sustaining a traumatic femoral diaphyseal fracture was included in the study. In both groups’ details of the injury, demographic details, other injuries sustained, treatment performed and length of hospital stay were recorded. In the prospective group clinical and radiographic assessments were made at three months and one year. The range of movement of the affected limb was measured and compared to the unaffected side.

There were 47 fractures in the retrospective group and 16 fractures in the prospective. In the retrospective group 94% were treated with traction, and in the prospective group the treatments were, early hip spicas 44%, external fixator 31% and flexible nails 19%. The mean hospital stay was 31 nights in the retrospective group and 16 in the prospective group. In the retrospective group 17% had a mal-union greater than ten degrees, and at three months in the prospective group this was 46%. Clinical follow up at three months in the prospective groups, they all had a full range of movement, and only two had any pain.

The use of varied treatments result in shorter hospital stay which allows children home earlier and reduces the demand on hospital beds. The children returned to normal function with a good range of movement using these modern treatments.